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NATURE AND TREATMENT
CONSIDERED ESPECIALLY IN REFERENCE TO THE
DISEASES OF THE INTERNAL ORGANS OF THE BODY
WHICH MOST COMMONLY TRODUCE IT.
PARTS I. AND II.
ANASARCA AND ASCITES.
TO WHICH IS ADDED,
CONTAINING A TRANSLATION OF THE WORK OF
DR. GEROMINI, ON DROPSY :
FROM THE ORIGINAL ITALIAN.
By EDWARD J. SEYMOUR, M.D.
PHYSICIAN TO ST. GEORGE'S HOSPITAL;
CONSULTING PHYSICIAN TO THE SEAMAN'S HOSPITAL;
AND ONE OF THE PHYSICIANS IN ORDINARY TO H. R. H. THE DUKE OF SUSSEX.
LONGMAN, REES, ORME, BROWN, GREEN, and LONGMAN,
Wtlson and Son, Printers,
SIR BENJAMIN BRODIE, Bart. F.R.S.
SURGEON TO ST. GEORGE'S HOSPITAL,
SERJEANT SURGEON TO THE KING,
THE FOLLOWING PAGES ARE INSCRIBED,
IN ADMIRATION OF HIS GREAT TALENTS, AMIABLE CHARACTER,
AND UNWEARIED ENDEAVOURS TO PROMOTE EVERY
IMPROVEMENT IN MEDICAL SCIENCE,
IN GRATITUDE FOR AN UNINTERRUPTED FRIENDSHIP OF MANY
Anasarca, or Dropsy of the Skin
The proximate or immediate Cause of Dropsy .
Anasarca from Rheumatic Disease of the Heart.
Anasarca from Enlargement of the Heart
Cases of Anasarca occurring without organic Disease
of an internal Organ —
1. From Cold applied to the Body
2. After Eruptive Diseases, especially Scarlatina
3. From Debility in young Females, with Sup-
pression of the Catamenia, or succeeding to
very large Discharges of Blood after Child-
birth, or from Accident
Anasarca from Disease of the Kidneys
Ascites, or Dropsy of the Abdomen —
1. From Contraction of the Liver after Inflamma-
tion, &c m
2. From Diseases of the Viscera supervening upon
Ascites from Disease of the Peritoneum 101
ON THE CAUSES AND CURE OF DROPSY,
From the Original Italian of Dr. F. C. GEROMINL
Of the Theories of Physicians to the time of Brown,
respecting the Causes which produce Dropsies ; and
also those of the great Anatomists who have illus-
trated (the structure and functions of) the Lymphatic
Of the sensible and well-known processes which pro-
duce an effect similar to Dropsy 135
Of the Diseases which frequently precede and generate
Examination of the nature of the Fluid of Dropsy, and
also of that which is naturally exhaled into the diffe-
rent cavities ; afterwards of the Organic Alterations
discovered in Dropsies 148
Of the Method of Cure pursued in all times, although
not always in accordance with the different Theories
of the Schools 161
Explanation of the Cause of Dropsy, taken from the
preceding Chapters 169
On the false opinions commonly put forward, from
errors of observation on the remote causes of Dropsy 173
Examination of the thirst and wasting which accom-
pany Dropsy 184
* The Seventh Chapter is omitted, as consisting entirely of arguments
against the Brunonian theory.
Explanation of the cure of Dropsy, derived from the
reasoning in the preceding Chapter : reflections on
that proposed by Cullen, by Milman, by Darwin, by
Rasori; and examination of the " modus operandi"
of remedies to promote it 194
The indications of the cure of Dropsy, derived fiom the
opinions lately explained 210
ANASARCA, OR DROPSY OF THE SKIN.
There is perhaps no disease upon which Patho-
logical Anatomy has thrown more light than
upon Dropsy. This disease is now generally
admitted, in its severest forms, to be a symptom
of organic disease of one or more viscera of the
body, in most instances arising from the return
of blood to the right side of the heart being ob-
structed, and the impaired functions of that
organ being relieved by the secretion of large
quantities of fluid ; the effusion being partial
where the obstruction is partial, but where the
obstruction is in the heart itself, sooner or later
extending through the whole cellular texture.
The ancient physicians, from their ignorance of
anatomy, had contracted opinions that the liver
was the principal agent in the formation of the
blood, and hence to its disease all cases of dropsy
were to be attributed : and when this idea dis-
appeared before a more perfect knowledge of the
structure of the human body, each sect of physi-
cians adopted some peculiar tenets of the school
to which they belonged, to explain the causes of
this fatal disease. These opinions will be found
treated of at large in the Appendix, from the
Italian of M. Geromini, who has investigated
what may be called the history of the doctrines
concerning dropsy, with singular labour, talent,
and spirit: and as it is my wish rather to clear
away than overload, I shall proceed directly to
the object I have in view, — the arrangement,
as far as it is possible, of these collections of fluid
under their primary cause — disease of one or
more of the viscera of the body.
It will be well first to glance at the ordi-
nary manner in which most frequently cases of
dropsy present themselves in hospital and private
practice, which wi 11 demonstrate the necessity of
the more detailed consideration of them.
How often does not the following case occur :
A patient, between twenty and thirty, or
younger, applies for relief, having difficulty of
breathing, increased on ascending a stair, or on
rapid motion, with constant palpitation of the
heart : he will relate that he has suffered from this
palpitation for several years, on any hurry, but that
latterly it has become constant ; that he lies down
in bed with difficulty*, and that latterly his ankles
and legs have begun to swell ; he has constant
thirst ; the urine is high coloured; there is short
dry cough, though he can inspire freely; his
nights are restless ; and when he wakes, his eye-
lids and cheeks are swollen : the pulse may be
either quick and weak, or full and soft — rarely
hard ; the urine, on examination, does not coagu- -
late by the admixture of acids, or by heat.
If further inquiry be made of the patient, he
will be found to have been affected at some re-
mote period, perhaps three or four years since,
by acute rheumatism, with redness, swelling, and
pain of the muscles and joints of the hands and
feet, shifting their position from limb to limb, with
fever; to have recovered from the attack, suffer-
ing more or less from palpitation ; and to have
become greatly alarmed at the recent appearance
of the swelling : on listening to the chest, a noise
resembling the blowing of bellows may be heard ;
the heart is felt beating over a large surface, and
the dress worn about the throat is perceived to be
agitated by the increased action of the organ.
The disease is enlargement of the heart after
adhesion of the pericardium. The effusion or
dropsy, in this case anasarca, is the consequence of
* This symptom is not constant.
the disease having advanced so far that the heart
is unable to circulate its blood freely.
A man in the lower class of life seeks admis-
sion into a hospital under the following circum-
stances : — He is enormously swollen ; the face,
hands, legs, and integuments of the abdomen,
hard, but retaining the impression of the finger ;
there is considerable difficulty of breathing, and
hard dry cough ; sometimes a little expectoration,
frothy and tinged with blood ; the urine is
scanty, and does not coagulate by the usual
methods; the pulse is hard, sometimes full ; the
heart is felt beating over a large surface ; the
tongue is often foul.
The disease is recent, and the patient still
strong, but greatly oppressed.
If such a case prove fatal, the heart is found to
be greatly enlarged ; its parietes, especially
those of the left ventricle and the septum, double
their natural thickness, and the cavities likewise
enlarged, but not in proportion to the increase
of the muscular structure.
This is a case of enlargement of the heart from
hard living, especially from drinking large quan-
tities of porter. The patient is generally under
fifty years of age. The dropsy is anasarca.
A woman, between 40 and 50, also applies
for relief, with inordinate swelling of the whole
body ; but here the surface is not only distended
and white, but the impression of the finger re-
mains at considerable depth in the integuments :
the pulse is quick and feeble, and even where
there is volume it is easily compressible; but it
is irregular, and there often is a grating sensation
communicated to the finger. The urine is small
in quantity, not very high coloured, but incoagu-
lable by heat or acid. There is great difficulty of
breathing, and often cough, with much mucous
expectoration. The labia are enormously dis-
tended, and the parietes of the abdomen so much
enlarged from infiltration, that, at first sight,
ascites, or dropsy of the belly, would appear to
be complicated with anasarca, but on striking
the abdomen this is not found to be the case.
If this case prove fatal, the heart will be found
greatly enlarged, but not in its muscular struc-
ture, or at least not in proportion to the size of
the cavities ; the enlargement arising from dila-
tation of the cavities, often also the valves do not
shut perfectly from deposition of bone, and
complicated with this is a dilatation of the root
of the aorta, with atheromatous deposit.
This case of dropsy, then, depends on the
disease of the heart, with dilatation of its cavities.
In all these cases there is a greater or less
degree of congestion or condensation of the
lungs. In the first case, from the disturbed cir-
culation ; in the second, from the action of the
same intemperance which produced the disease
of the heart ; in the last case, infiltration of the
cellular structure of the lungs is also present.
A patient, probably a young person, applies
for relief, with swelling of the lower extremities
and of the face ; the pulse is not weak \ there is
pain in the back, sometimes in either hypochon-
drium, and headache; no enlargement of the heart
is perceptible ; no violent palpitation ; no move-
ment over a large surface ; thirst ; no dyspnoea ;
the urine is abundant and pale coloured, but on
applying heat, or on the admixture of acid, a
coagulation, varying from flocculi to nearly per-
fect coagulation, takes place.
If the patient die, the heart will be found na-
tural, but the kidneys diseased.
This, then, is dropsy from disease of the kid-
These are cases of dropsy from disease of a
single structure ; but the causes which produced
them, especially the inordinate use of stimulating
liquors, may affect more than one. All the symp-
toms of dropsy from disease of the heart, with
coagulable urine (or disease of the kidney), and
with ascites from disease of the liver, may be pre-
sent. Such cases are to be considered afterwards.
By separating* the cases of one form of dropsy
from disease of a single organ, as it has occurred
to me frequently to have seen them, from more
complicated ones, we shall be better able to con-
template the history and treatment of those un-
fortunate cases in which universal dropsy takes
place, as a symptom of the organic disease of
In the following chapter I shall proceed to en-
deavour to explain more fully how the diseases
of these viscera individually produce certain forms
of dropsy, and the comparatively rare cases of '
dropsy from functional disease.
The proximate or immediate cause of dropsy
appears to consist in the secretion of fluid by the
capillary arteries, nearly resembling the serum
of the blood, more or less diluted, and in some in-
stances approaching very nearly in consistence to
the liquid secretion of lymph, which takes place
at the conclusion, and is one of the terminations,
of serous inflammation. Dropsies are generally
considered under the head of —
Anasarca, or dropsy of the cellular membrane ;
Ascites, or dropsy of the peritoneal sac ;
Hydrothorax, or effusion of fluid into the cavity
of the pleura? ; and Hydrops Pericardii, from
effusion into the cavity of the pericardium ;
Hydrocephalus, or effusion of fluid into the
ventricles of the brain.
Anasarca arises most frequently —
1. From disease of the heart.
2. From disease of the heart and lungs.
3. From disease of the kidneys.
These are the organs which, being diseased
either separately or together, are accompanied by
an effusion of fluid, which appears to relieve the
severity of the original disease at some period of
There is likewise a certain condition of the
vessels of the skin (after cold suddenly applied to
the surface of the body, or after the vessels of the
skin have been long stimulated during eruptive
diseases), in which the capillary arteries secrete
a fluid precisely similar to that which is poured
out as a relief to the congested vessels, in the
organic diseases to which we have referred.
The simplest form of dropsy of the cellular
membrane, is the swelling of a limb,, or the
extremity of a limb, without redness or heat,
the part retaining, in a greater or less degree,
the print of the finger impressed upon it, and
the skin being white and shining : this is termed
This oedema is found to depend either upon
tumours pressing upon the veins above the swell-
ing, or obstruction of the vein itself. The first
occurs, for example, in one leg, in ovarian dis-
ease, accordingly as the tumour within the pelvis
obstructs the return of blood through the iliac
veins, the minuter arteries secreting fluid, which
relieves the local congestion : if the tumour
change its place, or the pressure be relieved by
a horizontal position, the oedema disappears, or
is greatly diminished.
The oedema which takes place from inflam-
mation and consequent obstruction to a vein, is
seen in the legs after lying-in, in the arm after
phlebitis from bleeding, and often in a single ex-
tremity in those diseases termed malignant, or of
a cancerous kind ; where, on examination after
death, the vein will be found obliterated above
the swelling, often from a deposition of matter
not unlike what is found in the diseased mass,
the cause of the patient's death.
In every one of these cases the oedema is a
Wherever great obstruction exists to the re-
turn of blood to the right side of the heart, it
would be fair to conjecture, from what we see in
oedema in a single limb, that the whole venous
circulation would be congested, and hence the
whole capillary arterial system would secrete
fluid, as a relief to the obstruction ; and if this did
not occur, the balance of the circulation would
be in so disturbed a state as to cause rupture of
vessels in some vital structure ; and this we find
to be the case : the capillary arteries pour out
fluid into the cellular membrane, of greater or
less quantity, according" as the obstruction is con-
siderable, and of greater or less consistence as the
patient's vital powers are greater or less, or the
obstruction more or less sudden.
The oedema, in the first case, becomes now
termed anasarca, or dropsy of the skin ; the
swelling is generally more in the legs, from their
depending position, but the eyelids, cheeks, and
integuments of the abdomen, are often greatly
swollen, especially after sleep in a recumbent
position. If the swelling pitted deeply on pres-
sure, the skin being very white, and the forces
of the patient broken, this condition was called by
the ancients Leucophlegmasia ; where the swell- -
ing was more tense and resistent, and strength
less impaired, they employed the name Ana-
sarca. As these are shades of the same dis-
ease only, I shall, for simplicity's sake, employ
the latter term, as applicable to the whole
Anasarca, then, is only a symptom of disease of
an internal organ, with the exception hereafter
to be more minutely described, in which the
capillary vessels of the skin take on inflamma-
tory action after cold rapidly applied. I shall
proceed to shew, that in the majority of cases
this form of dropsy depends on a disease of the
heart ; reserving the cases of exception and their
application afterwards. In these cases the heart
is enlarged, sometimes with increase, sometimes
with diminution of the thickness of its parietes.
In such cases, when the valves are not diseased,
the pulse is increased in frequency, and some-
times, not always, in force, and the heart is
felt beating over a large surface. Such is ge-
nerally the case in anasarca in young persons,
in consequence of enlargement of the organ,
subsequent to rheumatic inflammation, and ad-
hesion of the pericardium. In anasarca from
enlargement of the heart, at a more advanced
period of life, the valves are also frequently
diseased : if the semilunar valves be the struc-
ture principally altered, the pulse at the wrist is
smaller, while the heart beats turbulently and over
a large surface in the thorax ; if the mitral valves
be diseased, there is more or less of a grating sen-
sation communicated to the finger on applying it
to the pulse at the wrist, and in either case the
pulse intermits. The same occurs as to the grating
sensation, when the heart is enlarged, and very
considerable alteration of the lining membrane of
the aorta above the semilunar valves, with dilata-
tion of that tube, is found ; atheromatous deposit
under the lining membrane, with portions of bone
being also found on dissection. In both cases, but
more especially the latter, the patient is subject
to very severe paroxysms of pain, lasting for the
space of some minutes, hours, or even days, but
alternating with intervals of perfect ease.
It is very remarkable, that disease of an artery
may take place to a very great extent without
dropsy occurring"; while enlargement of the
heart, unless death occur suddenly previously
to the obstruction of the return of blood to
the right side being considerable, is usually at-
tended with dropsy during some portion of its
progress. The effusion may indeed be got rid
of by remedies, and the organs of the body, ac-
customed to the increased action, and greatly
lowered in tone, still perform their functions,
without a return of dropsy ; but in such an in-
stance frequently a few months only elapse before
death, generally sudden, terminates the case.
The circumstance that the great arteries may
be diseased to almost any extent, without drop-
sical effusion, while the heart, much enlarged, has
its oppressed functions relieved by effusion, is of
considerable advantage in diagnosis of diseases
of this important viscus. The following is an
example : —
A patient in St. George's Hospital laboured
under considerable pain in the region of the heart,
without expectoration, and with only short dry
cough, ability to fill his lungs fully on inspira-
tion, and without pain. On inspecting- the thorax,
the heart was observed to beat very quickly, and
somewhat strongly ; its rapid motion being vi-
sible in the epigastrium, while the pulse in the
brachial arteries was small, and there was no
dropsy, neither had there been any effusion
during- the course of the malady. The ex-
tremely rapid and not weak action of the
heart, combined with the weak pulse, appeared
to me to denote that the heart was endeavour-
ing to overcome some considerable obstruction
to the circulation of the blood; produced by a
tumour pressing upon the aorta, or by an
aneurism. The case attracted considerable atten-
tion, and many gentlemen examined the chest very
accurately; all believed the heart to be greatly
enlarged, though much difference of opinion ex-
isted as to the presence of aneurism. My opinion
was decided as to the absence of any except
inconsiderable disease of the heart, because I had
never seen a case with so much disturbance in
the action of that viscus, arising from enlarge-
ment, without a greater or less degree of anasarca
of the lower extremities.
About a year after the patient had been in the
hospital, absorption of the ribs, at the posterior
part of the thorax on the left side, took place ;
and a large aneurismal tumour appeared, which,
after death, was found to have arisen in the de-
scend nig* aorta, and to have caused absorption of
the bodies of several of the dorsal vertebrae, but
the heart was in an entirely natural condition.*
* As such a case is somewhat uncommon, I subjoin an
accurate account of the post-mortem appearances, drawn up
at the time by Mr. Caesar Hawkins, Surgeon to St. George's
The descending aorta was enlarged into an aneurismal sac,
commencing about an inch below the left subclavian artery,
and terminating close above the diaphragm, the communica-
tion between the aneurism and each extremity of the sound
vessel being abrupt, and somewhat valvular by the projection
of the sac at each end beyond the part, which was still of its
natural size. This sac extended across the back part of the
left side of the chest to the ribs, three of which were completely
broken up into several portions, which were loose in coagula
of blood ; and another rib above and below these was carious,
and partly dead, but not broken into separate pieces. The
sac of the aneurism projected beyond the broken ribs, forming
a considerable tumour behind the chest, and having the latis-
simus dorsi muscle in contact with it. On the right side of
the chest, the aneurismal sac projected about three inches be-
yond the vertebras, but did not reach the ribs. The front of
the aneurism had the oesophagus in contact with it, and the sac
was partly indented and divided into two portions by this
tube ; the pericardium and part of the right lung were also
adherent to the sac, and on the left side the lung was in part
adherent to the sac in the same manner, but appeared also in
part to have been absorbed, so that the sac was in a measure
formed by condensed lung, where the pleurae were thus defi-
cient. On cutting into the aneurism from the chest, it was
found to contain chiefly recently formed coagula, but towards
the left side, where the ribs had been destroyed, there was a
good deal of solid coagulum in layers of some standing. On
emptying out the recent coagulum, several of the dorsal ver-
tebrae were seen to be extensively absorbed, and their surface
The dropsy which occasionally occurs in chlo-
rotic females may be add need as an exception ;
but, upon examination, it will be seen, that the
languid condition of the heart's action from want
of power gives rise to precisely the same condi-
tion, functionally, but in an inferior degree, to
what arises from organic disease in the former
instance. The heart is unable to impel the blood
to the extremities, and the capillary veins neither
receive nor transmit the blood with the same
rapidity as in a state of health. Congestion
of the venous system ensues ; hence oedema of
the ankles and legs, puffiness of the face, diffi-
culty of breathing : symptoms which are removed
by permanently increasing the heart's action by
steel, and all the usual means of promoting the
exceedingly irregular and knotty,, this appearance arising in
part from the destruction of the bone and intervertebral sub-
stance, but in part also from the deposit of new bone on the
exposed surface of the old.
The lungs were full of dark blood and frothy fluid, and
there was a considerable quantity of bloody serum in both
pleurae and in the pericardium. The heart was slightly en-
larged, the left side being a little thickened, while the cavities
of the right side were enlarged, without any increase of mus-
The ascending aorta was very much dilated, and its coats a
little altered in structure ; the centre of the anterior part of
the sac of the aneurism was at the same time seen to be formed
of the remains of the descending aorta, which was a good deal
loaded with steatomatous deposit, the rest of the sac being
composed of cellular structure, which had no definite separa-
tion from that part which was formed of the artery itself.
growth of the body — as exercise without fatigue,
dry air, animal food, &c. The same condition
arises after profuse bleedings or haemorrhage.
The obstruction of the circulation of the blood
through the minuter branches of the pulmonary
artery by disease, causes an inferior degree of
congestion in the whole venous system. This is
seen in cases of solidified lungs, either the result
of inflammation, or obstruction from tubercles.
The anasarca in this case is not so general as in
diseases of the heart, for a portion of the blood
still undergoes, from the extreme minuteness of
the ramifications of the artery, the usual change;
the alteration also has been slow, and the declin-
ing strength of the individual, from the injury of
this important viscus, has enabled, in some de-
gree, parts to accommodate themselves to the
change; i. e. the blood is in less quantity, and the
obstruction less considerable and sudden, than
after enlargement of the heart itself : hence the
dropsy is less severe, being confined to some de-
grees of oedema of the lower extremities for the
general dropsy, and effusion of fluid into the chest.
When the heart is enlarged, with disease of
the valves, anasarca is often present to a great
degree, and the obstruction to the passage of
blood through the aorta causes it to be thrown
back on the pulmonary veins, and large quanti-
ties of fluid are secreted, to remedy this important
congestion. To this the patient probably owes
his life, or at least the continuance of life during
some considerable time ; for without it, it is pro-
bable some of the larger branches of the pulmo-
nary veins would give way, and the patient die
Where the obstruction has continued, and the
consequent effusion has been considerable for
some time, the right cavities of the heart become
enlarged ; and at length the smaller vessels in
the lungs pour out blood, often in large spots,
to which condition the name of pulmonary apo-
plexy has been given, very improperly. In every
case, well marked, of this disease, which has
fallen under my observation, the mitral valves
have been most extensively and chronically dis-
eased ; and in the beautiful plate by M. Cruvel-
hier, the disease of this valve is prominently
displayed, as the cause of so extensive and fatal
an alteration of structure in the lungs.
In many cases of extensive disease of the lungs,
however, no dropsy is found. How is this to be
explained ? In such cases, expectoration takes
place in a very copious degree ; and this secretion
constantly removed,, and passing away from the
mucous membrane, or from a false membrane in
a vomica, affords the relief more safely to the
congested circulation of the patient, than that
which is effected by the effusion into the serous
cavities, or the cellular membrane in other
In these instances, therefore — consolidation of
the lungs, by inflammation, or crops of tubercles —
the oedema is only a symptom ; and the same
may be said to be the case of the hydrothorax
occurring* with extensive disease of the valves of
Frequent as is anasarca from diseases of the
heart, (enlargement with adherent pericardium,
after rheumatic inflammation in early life, and
enlargement with deposition of bone in the
valves, coronary arteries, or pericardium at the
root of the aorta in more advanced age), cases of
anasarca undoubtedly occur, independently of
disease of this important organ, or of the lungs.
This leads us to consider the two forms in which
the vessels of the skin may secrete fluid, after
causes applied, which produce inflammation.
(Cases from disease of the Kidney, afterwards
to be noticed.)
These are : —
1. Anasarca from cold suddenly applied to the
surface of the body.
2. Anasarca succeeding to eruptive fevers.
* In cases also of solidified lung from tubercles, even where
the expectoration is not considerable, diarrhoea or colliquative
sweats being often present, relieve the obstruction.
1st. After cokl applied suddenly to the surface
of the body, dropsy not un frequently appears,
J and this without organic disease. It is suffi-
cient to remember the extreme vascularity of the
cutis, the extensive secretion of perspiration over
the whole extent, the quantity of imperceptible
halitus or perspiration from the surface of the
body, amounting, in the best chemical and phi-
losophical estimate, to twenty-eight ounces in the
twenty-four hours, to judge that the impression
of cold suddenly applied, checking this necessary
secretion, would produce great mischief : the
consequence would necessarily be, either inflam-
mation of the vessels themselves, causing a secre-
tion of lymph ; or this process would be counter-
acted by an increased degree of secretion, or
exhalation, in other parts of the body. And
what in fact do we find to be the case ? Most
frequently when cold is suddenly applied to the
surface of the body, diarrhoea is the consequence ;
increased secretion and exhalation is formed in
the intestinal canal, and thus the repressed sen-
sible or insensible perspiration is balanced, and
no dropsy takes place. After cold suddenly ap-
plied, diarrhoea is common, dropsy rare • because
the repression of the discharge from one mucous
membrane is compensated by the secretion from
another : and it is only when this fails to relieve,
that this kind of dropsy takes place. Ordinary
fluids failing to be secreted, which it is the fane-
tion of these vessels to prepare, and no increased
secretion taking* place from the membrane, the
relation of whose properties with the mem-
brane covering- the body is so considerable, the
vessels secrete lymph, the whole cellular mem-
brane becomes distended, and the swelling* is less
elastic, more resisting, the skin more stretched
and shining-, than in the cases where a slow
relief is afforded to the obstructed venous circu-
lation. The action of the heart and arteries is
increased in force and frequency; the secretion
of urine is diminished, and high coloured ; the
tongue is white ; in fact, a feverish condition of
the body is formed ; blood drawn from the arm
shews the buffy coat ; there is intolerable thirst
present ; and the remedies, both indicated and
effectual, are those which diminish the increased
action of the heart and arteries, and control the
secretion of coagulable lymph, viz. blood-letting
In physics, it is sufficient for a cause to pro-
duce a given effect, and it is unphilosophical to
seek for more than one given effect to proceed
from a given cause. But widely different is the
effect of any given cause upon a body composed
of different structures, endowed with different
degrees of vitality, and with different functions
to perform ; and it is the absence of this consi-
deration which has made physicians resolve, that
a cause, absolutely, singly, and solely, can pro-
duce diseased function of vessels by inflamma-
tion, and inflammation alone. Thus Geromini
and his followers have advocated the point, that as
in inflammation of serous membranes, the vessels
pour out lymph under an aggravated form of
the disease, and fluid in a less intense degree of
inflammation, as a blister, for instance, applied
to the skin, causes an effusion of fluid, more or
less approaching to lymph, from the inflamed
vessels, this process is the sole one to which
dropsy can be attributed ; and hence that (which
is the unfortunate deduction) to remedies for
acute inflammation can its successful cure alone
That capillary vessels in serous membranes,
destined apparently to secrete a halitus, in order
to lubricate the opposing surfaces, (Cotunnius
long since proved by experiments on living ani-
mals, that this halitus did not coagulate ; hence
the fluid of dropsy is not the condensation of
this exhalation, as was formerly supposed, but
a new secretion,) secrete lymph or whey-co-
loured serum at the conclusion of inflammation,
by which the tension and increased action of these
vessels is relieved, is certain. That these vessels
should not likewise secrete fluid, when the circu-
lation is greatly obstructed, to relieve the con-
gestion of the veins, appears to me altogether
hypothetical. If, indeed, a morbid effect could
arise from one cause, and from that cause alone,
the conclusion would be determined. But with-
out entering' into hypothetical considerations, it
is certain that one and the same effect to all ap-
pearance, as far as the effusion of fluid is con-
cerned, may be produced,, by disease of the heart,
by obstruction to the circulation in the lung's,
by cold suddenly applied to the surface of the
body, by disease of the kidneys, and by eruptive
diseases; but the exciting cause need not neces-
sarily be the same.
ANASARCA, FROM RHEUMATIC DISEASE OF THE
The subjects of this disease are generally young,
and, with few exceptions, under forty years of
age. It has occurred to me to see this disease in
patients of nine years of age* : and the most se-
vere case I ever saw, that in which the disorgani-
zation of the heart had proceeded to the greatest
extent, terminated fatally at the age of thirteen.
A patient labouring under anasarca from rheu-
matic disease of the heart, has swelling of the
cellular membrane, having begun about the
ankles : the face is also swelled, especially the
eye-lids; there is an expression of anxiety, even
greater than in diseases of the chest in general ;
the pulse is generally small and quick, sometimes
intermitting, but very small compared with the
action going on within the thorax ; a tumultuous
beating of the whole organ : this smallness of
the pulse compared with the violence of the
* A patient, in St. George's Hospital, suffered from rheumatic
pericarditis at the early age of four years.
action in the heart itself, arises from the inordi-
nate growth of the organ, without a correspond-
ing enlargement of the vessels of the heart. In
the most remarkable case of this kind I ever saw,
the patient had laboured under the symptoms
during four years, having commenced at nine
years of age. The heart was enlarged to three
or four times its natural size at his death, with re-
peated layers of lymph glueing together the peri-
cardium : the aorta retaining' the size of that vessel
in a young boy of nine years. I have seen the
same effect produced in adults,, from contraction
of the aorta above the semilunar valves. If the
anasarca be very considerable, there is little pain
felt in the chest, the obstructed circulation being
relieved by the pouring out of the secretion from
the minuter vessels. If the effusion be only
commencing, there is almost always pain in the
region of the heart, often pain in the course of
the biceps muscle of the left arm, and cramps in
the legs : the patient is unable to lie down, and
the most easy position is bending forward over
the back of a chair. There is also in the early,
stage a disposition to syncope.
If the effusion has taken place for some weeks,
the pain and disturbance in the chest are less
felt, and the patient attributes all his sufferings
to the dropsy. The legs are tense ; the face
swelled, and of a pale bluish tint; great difficulty
of breathing ; the urine very scanty and high
coloured, and where unaccompanied by disease
of the kidney, does not coagulate by the usual
method ; the pulse quick and weak ; the surface of
the body cold ; there is present a short dry cough
without expectoration, or with a very slight frothy
expectoration, occasionally tinged with blood.
When a patient applies for relief, labouring
under these symptoms, the first question to be
asked is, — Have you suffered from rheumatism ?
or rather, as rheumatism in its ordinary sense is
understood to apply to pains of all sorts, — Have
you suffered from redness, swelling, and pain, in
the limbs, confining you to bed ? The answer is
generally —About a year ago ; or sometimes, two
years ago. Occasionally the patient has experi-
enced repeated attacks, or one very severe attack
has preceded the symptoms by a few months.
In such cases the pathological appearances are
uniformly, enlargement of the heart itself; the
parietes thickened, especially those of the left
side, and the cavities also larger than natural ;
the enlargement, however, not being in propor-
tion to the increase in thickness of the walls of
the heart; the pericardium is glued together by
layers of lymph, often of old formation, and
even organized, rarely (when life is terminated
by dropsy) very recent.
In the notes of thirty cases, which I have seen
in St. George's Hospital and the Seamen's Hos-
pital, tog-ether with some in private,, these patho-
logical appearances have never failed to occur in
a single case. In all such instances the account
of the rheumatic fever which had occurred at a
greater or less distance of time previously, was
clear, distinct, and well ascertained. This form of
dropsy from disease of the heart is perhaps the
simplest view of the cause and effect ; because it '
occurs in young people, before excess in the use of
ardent spirits, or exposure to great changes of
temperature, (the fruitful sources of diseases
of the viscera), or before the advance of time has
begun to injure the soundness of internal organs.
Where diseases of the heart, terminating in ana-
sarca, arise from the immoderate use of malt
liquor, or ardent spirits, the same cause produces
diseases of the liver, of the lungs, and often dis-
ease of the kidneys ; and the anasarca is accom-
panied with ascites, and with all the evils of a
digestion nearly destroyed. But in anasarca after
rheumatism, the viscera are generally unim-
paired ; the alteration in the structure of the
heart being the sole cause of the disease, which,
from its striking appearance and distressing
nature, is immediately looked upon as the prin-
The prognosis of anasarca from rheumatic
disease of the heart, is always unfavourable ; but
it is to be remarked, that the disease is often
more chronic, even in its most severe forms,, than
dropsy from disease of the heart arising* from
other causes. 1st, Because the disease frequently
occurs in young persons ; and if the severity of
it be relieved in the first instance, the growth of
the chest enables the impaired action to be better
borne. Thus I have seen the disease, in a most
• severe form, endure during five years. 2dly, Be-
cause not being the result of excess, spirit-drink-
ing, &c. other organs have not suffered from a
similar cause, as is so frequently the case in
anasarca after such indulgences.
The treatment of anasarca from this disease of
the heart, varies according to the degree of inflam-
mation of the pericardium going on at the time
of the effusion : if it has been immediately pre-
ceded by pain in the organ, and some swelling*,
redness, or pain in the limbs, inflammatory action
undoubtedly exists, and the means to relieve it
must be had recourse to. Blood-letting, not in
any large quantities, and taken from the patient
when lying in a horizontal posture, so as to re-
lieve the organ, without producing fainting, (for
it is to be remembered, if the patient faints he
may not recover,) is the first remedy. To this
should succeed the employment of calomel and
opium, (than which no remedy, it is well known,
is more successful in arresting the progress of
inflammation of serous membranes.) Three grains
of calomel and a quarter of a grain of opium may
be given every four hours : a blister may be ap-
plied over the region of the heart, and a strictly
low diet enjoined.
It may here be remarked, that the quantity of
mercury which may be administered with the
greatest advantage, in this state of disease, (when
inflammation ending in deposition of lymph is
going on in the pericardium), is almost incon-
ceivable to those who have not witnessed it,
without affecting the gums, or producing any
inconvenience whatever. It has occurred to me
repeatedly to see from fifteen to twenty grains,
in the acute form, given during ten days or a
fortnight, without any affection of the gums, or
any appreciable effect, except the relief of the k
symptoms : the breathing being improved, the
anasarca disappearing, the sleep tranquil, and
the pulse being restored to its regularity.
In this form of the disease, where blood-letting
is useful, and calomel and opium most efficient
in restraining the action of the minute vessels,
the most useful diuretic, in my experience, is
nitre : from ten to fifteen grains may be given
in mint-water, twice daily. The quantity of
urine secreted under this course, is sometimes
very great, and with the most manifest relief to
the patient. The preparations of colchicum in
dropsy arising" from enlargement of the heart,
the consequence of rheumatic disease, would na-
turally, both from their presumed specific power
in rheumatism, and also from their diuretic
effect, appear to be indicated, but I cannot speak
favourably of their employment : on the con-
trary, great depression of vital power, with in-
creased irregularity in the action of the heart, is
often the consequence; and I do not remember
any case in which benefit appeared to be derived
from their employment. How unlike the effect
produced by them in effusion into the joints,
which caused them, under the name of Hermo-
dactyls, to be termed by the ancients " Theriaca
The above treatment applies to the cases in
which dropsy has appeared consequent upon en-
largement of the heart from rheumatism ; the
inflammation of the pericardium still going on
in an inferior degree to that which originally
I proceed to notice the treatment where the
inflammatory symptoms have ceased ; when the
patient has for months laboured under effusion
into the whole cellular structure of the body.
The limbs, integuments of the abdomen, face,
and scrotum, are greatly swelled, the urine
scanty and high-coloured ; there is great dysp-
noea; the pulse full, but easily compressible;
and the limbs, which in the former case were
swelled and hard, admitting the print of the
finger only on deep pressure, are lax, white, and
receive deep indentation from slight pressure.
Here the great object is to unload the system by
diuresis, and thus to relieve urgent symptoms ;
and here we may have recourse to the prepara-
tions of digitalis with the happiest effect.
Dr. Withering has remarked in the work which
first formally introduced this medicine into prac-
tice, that it will be found most effectual in a lax
state of the system, where the effusion is consi-
derable, and the action of the heart and arteries
feeble; and this, in my experience, is uniformly
the case. The infusion of digitalis is the prepa-
ration most effectual as a diuretic, and it will, in
the state of the system to which I have alluded,
be found more frequently to succeed than any
other. The formula which I have found more
certain than any other, is the following : —
R Infusi Digitalis, 3iv.
Liquor. Oxymur. Hydrarg. 3ij.
Aq. Menth. Sativ. 3viij.
Tras. Oantharidis, tttxxx. M. Fiat haustus bis
terve in die sumendus.
The Tinct. Cantharidis*, in itself an active diu-"
retic, renders almost every other more effectual ;
but it is contra-indicated in aged persons, where
disease of the urinary organs is present. The
rapidity with which the above draught operates,
is quite astonishing: I have seen as much as a
gallon and a half of urine voided in one night,
after the second day of its employment. From
the presence of the oxymuriate, however, it will
sometimes purge — an effect to be prevented ;
■ for this purpose, a pill, consisting of a grain of
opium, should be given every night, at bed-time.
It is obvious that the enlargement of the heart
continues, when the dropsy which relieved the
obstructed circulation is carried off by remedies,
and that the patient has a crippled existence ;
but in the more opulent classes of society, his
life may be spared many years : not so with the
poor man ; he must return to the rapid changes
of temperature — the originally exciting cause of
the disease — and to all those circumstances which
especially influence the diseased organ, viz.
toil, anxiety, vexation, and want. Hence the
numerous and unhappy relapses which are seen
in hospital practice.
Anasarca, from the disease of the heart, also
* This subject, and that of diuretics in general, will be dis-
cussed in a subsequent chapter.
occurs from enlargement of this organ, from spirit-
drinking, or the inordinate addiction to porter
(common in this chy), or from long-continued
anxiety, and great mental distress. In the first in-
stance, the heart is much enlarged, principally
with increased thickness of the parietes of the left
ventricle, and the septum between the ventricles :
it occurs from twenty years of age to sixty, and is
almost invariably attributable to intemperance.
The anasarca in this instance is enormous,,
the whole cellular membrane of the body being
greatly distended ; the integuments of the ab-
domen being increased to a size which appears
at first sight impossible, without effusion into the •
abdominal cavity, and yet on striking the abdo-
men no fluctuation is perceived. In extreme
cases, the distention is so great that the cutis
splits into laminoe, giving the appearance of fine
threads, dividing its texture transversely ; at
others, effusion takes place, in large blisters on
the legs and extremities, which by bursting and
discharging serum, for a time alleviate the dis-
tress. The pulse is generally strong and quick,
the urine seanty and high coloured, and does not
coagulate by heat, or the admixture of acid ; the
tongue is furred, the patient obliged to be raised
in bed, and complaining of an insupportable
oppression. The face is swollen, and often
with a bluish tint, and there is constant thirst ;
the bowels are generally natural in their func-
tions, and the appetite little deranged.
Now, where such a combination of symptoms
from such a cause arises, it is natural to look for
the most obvious relief ; and from the swelling
and effusion occupying a continuous surface, to
relieve it by scarifications ; and, in fact, this is
for the time very effectual : an incision of about
two inches, just above each inner ankle, will
reduce in a few days the enormous effusion, and
the consequent oppression of the patient. I have
seen two gallons of fluid discharged in three days
from such incisions, and the dropsy entirely re-
- duced, but in almost every hospital case, erysi-
pelas first, and subsequently gangrene, super-
vened, and the patient died. Acupuncturation
in dependent parts produces an inferior degree
of relief, but with less danger — in hospital prac-
tice at least : I have seen this operation followed
by erysipelas and gangrene, although far less
frequently than in the other more decided and
Either of these modes of treatment, however,
only relieves symptoms, and some remedy is ne-
cessarily sought for, which, while it expels the
fluid, by increasing the natural excretions, and
thus effecting a vicarious drain, may diminish
the increased force and violence of the heart's
action. The first of these is the elaterium : this
very important medicine may be used where the
strength is yet unbroken, however great may
be the oppression from the extent of the ana-
sarca, and the relief has often been so great and
so permanent as to induce physicians to believe
that not only has the fluid, the symptom of the
disease, been got rid of, but that the actually
increased bulk of the parietes of the heart is
diminished. Bloodletting should be premised,
both with a view of unloading the congested
venous system, and of promoting absorption : (it is
well known from the experiments of Magendie on
the injection of poisons, that their operation was
greatly quickened by premising bloodletting;) and
afterwards the elaterium should be given in the
following formula, beginning with half a grain : —
R Elaterii*, gr. §.
Pulv. Capsici, aa. gr. ij.
Conf. Ros. Canin. q. s. ut ft. pilula, mane sumenda.
* It must observed, that the elaterium is most applicable in
cases where the bodily powers are yet strong. Thus I was
more successful in its use, in cases in the Seamen's Hospital,
where the patients were hardened by exercise, and inured to
exposure, than in St. George's Hospital, where many of the
patients are from a class accustomed to long confinement and
little exercise. Improperly administered, elaterium is apt to
produce a diarrhoea, from which the patient never recovers.
Dr. Cullen used very successfully three grains of gamboge
with sugar, every three hours. Such practice, though it pro-
duces frequent watery evacuations, is very inferior in power to
Such a form will operate very frequently by
stool, producing many liquid evacuations, and
accompanied for the most part by severe bilious
vomiting", the effect of which, as is well known,
is to produce a very active state of the absor-
bents. Thus Forestus speaks of an ascites cured
by sea-sickness; and the recession of tumours,
under the action of vomiting*, has long" been
It is very remarkable how much oppression in
such cases imitates true debility.
It occurred to Dr. Chambers and myself to be
called to a patient who laboured under enlarge-
ment of the heart and great vessels : the effusion
consequent on the former had been repeatedly
removed by remedies, but had returned to so
great a degree, that he had been three days in
making a journey of sixty-five miles ; and his
medical attendants had hesitated as to very small
quantities of purgative medicine. On the even-
ing of his arrival in London, he was bled, had
his scrotum punctured, and took elaterium, which
was repeated every alternate day for several
weeks, with the decided advantage of undoubt-
edly prolonging his life.
When this remedy fails, or when it ceases to
have the desired effect, I have succeeded in a
manner which has greatly pleased and surprised
me, in evacuating the fluid by large doses of
cream of tartar. Small doses of this salt are
among the most popular remedies for dropsy,
increasing the flow of urine, whether as a be-
verage with lemon peel and ginger, under the
name of Imperial, or with gin and sugar made
into a kind of punch, whose diuretic properties
are undoubted. But about seventy years since,
Menghini, an Italian physician, recommended
this medicine in far larger doses, as a deob-
struentj and averred that he had cured many
cases of dropsy by its exhibition*.
* The principal cases related by Menghini, are those of
ascites after diseases of the liver and spleen, maladies very
common in Italy. The following, however, is one of the casea
similar to those in which I have seen this remedy more effec-
tual ; and it is also a good specimen of the manner in which
these diseases are described.
I have little doubt that the patient laboured under disease of
the heart, with dilatation of the aorta, which gave rise to the
" asthma primo convulsivum turn humorale," described in the
" Invaserat mulierem quinquagenariam, biliosam, et habitus
corporis macri, et rigidi, asthma primo convulsivum, turn
humorale, cujus causa repetenda videtur a longiore mora in
frigida, ut lintea lavaret. Cum hunc morbum plures menses
tulisset, tandem die quarto Junii, annii 1755, se in Nosocomium
recepit. Quae emolliunt, incidunt, et urinas blande proliciunt
mensem unum fuerunt utiliter adhibita. At decrescente pau-
latim respirandi lahore, aggrediebatur sensim cedema primo
pedes, turn crura, deinde coxas postremo et faciem. Hae
partes quin et abdomen sex dierum spatio, ob vesicam et
He recommended an ounce to be taken every
morning in water ; the salt requiring about thirty
parts of boiling water for its solution ; and states
that patients recovered with the use of no other
remedy : he adds, that the urine let fall a sabulous
deposit at the time. Dr. Home, in his clinical ex-
periments, has related a very large number of
cases cured by Menghini's method. But as the
organic disease is very different in different cases,
as a glance at the histories will determine, no
scientific deduction can be drawn as to which
kind of dropsy, or to what disease of organ, the
remedy is especially applicable.
The tartaric acid, united with an alkaline base,
has always been considered, for reasons which I
am unable to explain, especially applicable in dis-
alvum segnius fluentem supra modum tumuerunt. Hinc Sitis
non modica, vigilia, cibi fastidium. .Venter, tametsi summopere
distentus, percussus tamen aquam intus absconditam non
" Cum heec sic essent, spem non levem habui de Tartaro :
quam auxit turn celer corporis totius tumiditas, turn conjectura
de aquae absentia in ventris cavitate. Jam ergo non quem-
admodum alias tartari drachmas quatuor, sed binae tantum sin-
gulo die dantur. Arbitratus quippe sum remedium licet par-
cius, tempestive tamen datum eodem liberalius_, ut serius
dato, plus profecturum. Et sane res bene cessit, nam alvo
prompte et pluries obsequente, et urinis crassis, sabulosis
et ad uncias aliquando octoginta fluentibus, universus corporis
tumor dierum quindecem spatio, nullo superstite, respirationis
vitio, omnino desedit." — Vincent. Menghini Institute Bononi-
ensi. Vol. iv. page 277.
eases of the liver. The tart, potassae especially
was considered as a deobstruent in bilious ob- *
structions, and the sulphate of potash in glan-
dular obstructions : hence for ascites depending
on disease of the liver, it would be reasonable to
choose this remedy; but, in my experience, it is
in anasarca from disease of the heart that this
method proposed by Menghini is most effectual.
I have repeatedly succeeded, even where ela-
terium has failed in removing the dropsical effu-
sion, by this method. An ounce of cream of
tartar is directed to be taken every morning in
solution, or if this acts too violently by stool,
half an ounce will be sufficient. After the fourth
day its beneficial effects generally commence.
The next case of anasarca from disease of the
heart, is where this organ is greatly increased in
size, with attenuated parietes. Such cases occur
in constitutions broken by habitual intemper-
ance, or debilitated by affliction, long-continued
anxiety, great watching, and sometimes after
long-continued and profuse evacuations — more
frequently in females than in males; and the
1 disease is more common in advanced age than
the other forms of anasarca from disease of the
The pulse is weak, often irregular ; at least,
even where there is volume, it is very compres-
sible. The anasarca, which is very extensive,
takes more the form of what has been termed
leucophlegmasia : the face is swelled, and of a
ghastly white appearance, while the integuments
pit on the slightest pressure. The effusion is
always preceded by difficulty of breathing, espe-
cially on any quick motion, by violent palpita-
tion, and disposition to syncope. The difficulty
of breathing is not, as in the former instance,
much relieved at first by the effusion ; for not
unfrequently the cellular membrane connecting
the lobules of the lungs is infiltrated also.
It is in this form of dropsy that sudden death
frequently occurs. The patient may be appa-
rently doing well, the swellings gradually re-
ceding, when a sudden return of effusion, either
into the chest or pericardium, is followed by
almost instant death.
This form also is often complicated with di-
latation of the arch of the aorta, and deposition
of atheromatous matter with spicula of bone
under the lining membrane. In such cases there
are not only all the evils arising from oppression
and distention present, but also paroxysms of most
severe pain, similar to what is experienced in
ossification of the coronary arteries, and is termed
It is in this form of the disease, where the tone
of the system is much impaired, that the prepa-
rations of digitalis as diuretics are most effec-
tual ; and it is in their application to this con-
dition,, that Dr. Withering' s original observations
on the use of this medicine are borne out in their
full force and accuracy.
" 1. It seldom succeeds (says Dr. Withering)
in men of great natural strength, of tense fibre,
of warm skin, of florid complexion, or in those
with a tight and cordy pulse.
" 2. If the belly in ascites be tense, hard, and
circumscribed, or the limbs in anasarca solid
and resisting, we have but little to hope.
" 3. On the contrary, if the pulse be feeble
and intermitting, the countenance pale, the lips
livid, the skin cold, the swollen belly soft and
fluctuating, or the anasarcous limbs readily pit-
ting under the pressure of the finger, we may
expect the diuretic effects to follow in a kindly
This medicine may be combined with squill
and mercury, as in the pil. hydropica, (pil. hyd.
gr. iij. ; scillse exsicc, pulv. fol. digitalis, aa. gr. i.)
or in infusion with the liquor, oxymur. hydrarg.
in mint water ; and if the patient labour under
no disease of the bladder or urethra, with the
tincture of cantharides.
To the addition of this medicine the tincture
of cantharides (as I have before hinted) to the
infusions of digitalis, of spartium, or of pyrola
umbellata, I am convinced, by repeated expe-
rience, the most complete diuretic effect is to be
attributed. I had, indeed, read that Dr. Wells
had succeeded in producing diuresis with the
tincture of cantharides, in three cases out of
five, in dropsy, with coagulable urine, but I
was first led to employ the preparation after a
consultation with Sir H. Halford, on a case of
That experienced physician related two cases
of this most fatal disease, which he had seen,
after the stage of effusion was established, re-
cover, in consequence of a very abundant diuresis
ensuing* on the administration of the tincture of
cantharides. Hence I added this preparation to
the infusions of diuretic vegetables ; and have
succeeded more uniformly in expelling- the fluid
with the infusion of digitalis, combined with
oxy muriate of mercury, with the addition of
tincture of cantharides, than with any other diu-
retic preparation I have used, or seen used, in
This leads me to say a few words on the in-
ternal use of this very important preparation, not
only in this but in some other serious diseases.
Cantharides have been recommended from very
high antiquity, and have been employed, and
afterwards laid aside or neglected, partly from
their irritating effects when they are incau-
tiously exhibited, and partly from their partaking
of the uncertainty of all diuretic medicines, (Dr.
Wells's cases might well have awakened a spirit
of inquiry,) partly because of the condemnation
of Dr. Cullen, who says, " they failed certainly
in the hands of Dr. Carmichael Smyth, who
asserts that, in his frequent exhibition of the
tincture of cantharides, he never once observed
the secretion of urine increased.' *
In modern practice they have been recom-
mended by Cloqnet, who believes that in sub-
stance the cantharides produce strangury, but in
liquid are diuretic. In aged people, and those
labouring under any disease of the prostate or
of the mucous membrane of the bladder, I fear
it will be found that in tincture, as well as in sub-
stance, the cantharides produce this very painful
It may be here permitted also to make a few
short observations on the great influence which
this medicine exercises over certain cases of
I have succeeded beyond my hopes in restoring
the use of the limbs in early life in this dreadful
disease. It has been long known to be useful in
such cases; and in pressing it upon the consi-
deration of the profession, I am advocating no
very novel practice, though the successful cases
are scattered though different works. In all the
cases in which I have seen its administration
effectual, it has acted as a powerful diuretic ;
and if Dr. Baillie's opinion be correct as to one of
the causes of this disease, (" if there be any
effusion of serum between the membranes of the
brain, which is a very common occurrence^ a
portion of the serum may fall into the cavity of
the theca vertebralis, and press upon the lower
part of the spinal marrow,") this diuresis will
sufficiently explain its utility in the palsy of the
The following cases are remarkably striking
ones : —
William Mowland, set. 29, was admitted into
St. George's Hospital, July 22, 1835, affected
with palsy of the upper and lower extremities :
two years before he had suffered from paralytic
affection of the hands in a less degree. On ad-
mission, he was unable to stand, or feed himself ;
his intelligence was entire, but all movement of
the extremities suspended ; the sensibility in the
lower limbs was likewise impaired ; his appetite
and digestion nearly natural \ he passed his stools
and urine at times involuntarily ; his sleep was
much disturbed. Pulse 80 ; tongue clean.
I ordered strips of blistering plaster to be ap-
plied to the spine, and the vesicated surface to
be dressed with mercurial ointment, being* the
most effectual practice in palsy with which I was
acquainted : his bowels were also ordered to be
kept open. This treatment was repeated three
times, and some increased degree of power over
the lower extremities appeared to be the conse-
quence ; but as the case did not progress, I re-
quested a consultation with my friend and col-
league, Dr. Chambers : it was agreed to give
him the tincture of cantharides.
On the 28th of August, thirty minims were
ordered to be taken thrice daily, in water.
In two months, during which the practice was
never varied,, he recovered the entire power of his
limbs, and the sensibility returned : the extensor
muscles of the fore-arms alone remained disobe-
dient to the will. (He had never worked in
lead.) Splints were ordered for these. In four
months from the beginning of the disease he was
able to walk out, and to help himself, weakness
only of the extensor muscles remaining: at this
time a slight strangury came on ; and it is re-
markable that this did not occur until the dis-
ease, for which the can tha rides was prescribed,
had almost entirely ceased. Camphor, and the
use of the warm hip-bath, relieved the symptoms.
He remained in the hospital during" the winter,
in order to test the permanency of his cure, and
left it quite well in March 1836.
Henry Mansell, a prize-fighter, set. 22, was ad-
mitted, in the winter of 1834-5, into St. George's
Hospital, after a pugilistic match, in a state
which gave reason to believe he suffered from
concussion of the brain. He recovered his senses,
but remained paralytic of the hands and legs.
He was unable to stand ; and in order to move
from place to place, crawled forward, shoving
himself onward with one leg, as children do
when first learning to walk : the sensibility in the
legs was almost destroyed. He was during some
weeks under the care of Sir B. Brodie, who re-
lieved the affection of the brain arising from the
accident : subsequently he was transferred to my
care. He had used full doses of strychnia with-
out the least benefit : all the animal functions
were natural, (pulse 60.) I ordered him to be
cupped once in every fortnight, from the nape of
the neck, and blisters to be applied in succession
over the spine, and dressed with mercurial oint-
ment. Great relief was afforded by this treat-
ment : he recovered the use of his arms and
hands, and greatly increased power over the lower
extremities. At this time I ordered him the
tincture of cantharides, as in the former instance,
and very rapid progress was made. In less
than a month he was enabled to walk well on
crutches ; and so satisfied was he with the hope
of ultimate recovery, that he left the hospital at
his own desire.
The recovery in this instance was preceded
by creeping pains along the course of the spine
and in the limbs, occasionally very severe : they
were relieved by the sp. ammon. succinat. in
camphor mixture : these pains exactly resembled
at times the aura epileptica.
I have seen one more case recover under this
treatment : and there is one other case now in
the hospital, under the same course, with every
prospect of success.
MM. Merat and Lens, in their beautiful work
on the Materia Medica, wind up their observa-
tions by the following remark on cantharides, to
the truth of which I entirely subscribe : —
" Mais c'est en teinture surtout qu'elles sont
bien indiquees : c'est dans ce cas un des moyens
a la fois les plus efficaces, et compart a la phi-
part de ceux qu'on y emploie, les moius re-
do ub tables*.
The nitrate of potass in solution, in the dose of
fifteen grains; the acet. of potass, in the dose
of from one to two drachms, either in its usual
form, or made by neutralizing in solution the
carbonate of potass with the vinegar of squillsf ;
may be given in a draught, with a pill, consist-
ing of three grains of the blue pill, several times
in the day ; or a kind of punch may be given, made
with cream of tartar instead of lemons, to every
pint of which two ounces of gin may be added :
all these are very effectual diuretic drinks. The
latter is very convenient in hospital practice.
The spirit of nitric aether may be added, in
the dose of a drachm, to a draught containing
ten grains of nitre dissolved in mint-water; or
it may be given as a beverage in the proportion
* Dictionnaire de la Matiere Medicale ; Art. Meloe vesicator.
-J- The following was a favourite prescription of the late Sir
F. Milman : —
R Aq. Menth. Virid. 3j.
Aq. Purae, %ss.
Carb. Potass, gr. xv.
Aceti distill. 3vj.
Aq. Pip. Jamaic., Syrupi, Aceti Scillae, aa. 3j.
M. ft. haustus.
of two drachms, or two drachms and a half of
aether, in six ounces of water : in this latter form
it is not disagreeable.
The spirit of nitric aether, the compound
spirits of horse-radish or juniper, can scarcely be
given in sufficient quantity to have any decided
effect ; but they may be used in private practice,
as "adj n vandal
As the disease advances, if no advantage be
obtained from the remedies mentioned,, the pa-
tient or his advisers seek, from the long list of diu-
retic remedies, other means to get rid of the fluid.
The preparations of squill, when combined
with mercury, are better adapted to cases where
blood-letting is necessary, because this medicine
by its nauseating properties diminishes the force
and power of the heart ; but in the case we are
' considering, there is increased action with di-
minished power. Dr. Withering recommends the
employment of squill in those cases in which,
from the strength of the pulse, the recent nature
of the disease, and the youth of the patient, little
is to be expected from the diuretic effects of digi-
talis. Another difficulty presents itself in some
cases — that extreme irritability of the stomach is
induced, thus prohibiting the practitioner from
the use of nearly all internal medicines. This
has not escaped the observation of the French and
Italian physicians ; some of the latter, especially
Brera and Chiarenti, recommend the employment
of this remedy in friction, and speak of its decided
success. I have employed this mode of administer-
ing the squills in the wards of St. George's Hos-
pital, and would speak with diffidence of the
result of a very few cases in which it was ordered.
Half an ounce of the dried powder of squills was
mixed with double the quantity of hog's-lard, and
a drachm rubbed in thrice daily over the abdomen
and the inside of the thighs : this was only in cases
in which the extreme irritability of the stomach
prevented the administration of the ordinary
preparations of this plant. Of the inunction of
Veratria ointment, as recommended in recent
publications, I have little experience; in the few
cases in which I employed this most expensive
remedy, no advantage was derived from its use.
Of the hydriodate of potass as a diuretic, I can- -
not speak favourably injny own experience; the
value of this medicine, in another form of dropsy,
will be referred to hereafter.
The school of Montpellier long since exploded
the popular, but most erroneous, doctrine, that
drinking freely was injurious to dropsical pa-
tients — an idea as old as those Grecian schools
of physic which recommended spices and wine
as corroborants in this disease ; and sometimes
exposed the patients to the ardent rays of a
southern sun after covering- him with ointments
made of honey, lees of wine, and other stimulant
preparations, with a view of drying up the su-
The most celebrated remedy for dropsy in France
before the Revolution*, appeared to owe a large
part of its efficacy at least to the copious draughts
of weak beef-tea (bouillon) ordered during its ad-
ministration. The pills themselves, each of which
contained half a grain of a drastic purgative
(the extract of black hellebore), were given six at
a time, early in the morning, and repeated at mid-
day, the patients drinking copiously during the
operation ; but the author of this method, either
unable to withstand the doctrines of the humoral
pathologists with whom he was surrounded, or
willing to persuade, rather than argue with the
world at large, and their popular idea of debility,
called his pills, the basis of which was a drastic
purgative, increasing all the secretions, by the
name of " Pilules Toniques." In my expe-
rience, the pills of Bacher are infinitely inferior
in power to elaterium.
* Bacher's pills consist of half a grain of extr. hellebori nigri,
half a grain of myrrh, and nearly half a grain of the powder of
■ the card, benedictus : the infusion of the latter plant is a feeble
bi\t popular diuretic.
It is now about twenty-five years since Dr.
Somerville,sen.* made known generally the pow-
erful effects of the pyrola umbellata as a diuretic.
It has not been sufficiently employed to enable us
to determine to what cases its administration is
particularly adapted. In very languid cases of
anasarca, where the swellings are of long stand-
ing, and other remedies have failed, I have been
agreeably surprised by seeing a full flow of urine
established, and great relief afforded. It is best
administered in infusion, an ounce of the leaves
and stalks being infused in a pint of water, which
should be drunk during the day. It sometimes irri-
tates the urinary passages violently, and should
therefore not be used in cases of advanced age, or
where the patient has suffered from stricture.
The infusion or decoction of the twigs and
stems of the spartium scoparium has long been a
remedy adopted in the country to produce diu-
resis. It may be given in decoction, an ounce
of the broom tops being boiled in a pint and a
half of water to a pint, and mixed with an equal
quantity of hot milk, or in infusion, as common
tea. It has appeared to me to be more useful in
the convalescence of patients than early in the dis-
ease, keeping up a diuresis already established, and
promoting the general strength of the patient.
* In the Med. and Chir. Transactions.
Sydenham recommends the ashes of this plant
dissolved in white wine; and, latterly, the seeds
have been greatly recommended in Germany in
similar cases, a drachm of them being taken
twice daily in two ounces of white wine. I
have only seen this remedy employed in two
cases, and in both without the smallest effect.
The allium sativum (garlic) has been very
strongly recommended by the most competent
• authorities in dropsy, especially in anasarcous
swellings which accompanied asthmatic com-
plaints, — cases in all probability arising from en-
largement of the heart, with dilatation of the
Forestus, Sydenham, and Cnllen, all speak in
the highest terms of this remedy. Two or three
cloves are recommended to be swallowed several
times in the day. It has occasionally in my ex-
perience proved grateful to the stomach, but not
effectual as a diuretic.
The flowers and stalks of the apocynnm can-
nabinum, or white hemp, were, a few years ago,
recommended from America as a most powerful
diuretic. I employed this herb in infusion in
two cases of dropsy, in St. George's Hospital ;
but it proved in both far inferior either to the
digitalis or the pyrola, in promoting the flow of
urine, and in one case produced much distress
and vomiting, with a weak and irregular pulse.
The application of cabbage-leaves to the calves
of the legs in anasarca, is sometimes attended
with a considerable discharge of serum from the
skin : the effect may be rendered more certain
by rubbing the anasarcous legs gently with vo-
latile liniment previous to the application of the
Looking to the observation of several years in
these cases, I should say by far the most effectual
diuretics stand in the following order of utility: —
Infusion of Digitalis with Tinct. Cantharid.
Nitrate of Potass.
Supertart. of Potassae with Sp. Juniper. C.
Pil. Hydrarg. Pulv. Dig. et Scilloe exsice. ;
in form of pill.
Acet. et Tinct. Scillse.
Infus. Pyrolee Umbellatae.
Sp. iEtheris Nitrici.
Sp. Armoraciae Comp.
If the swellings in such a case be of recent
date, such means will often suffice to carry
off the water by diuresis, and careful attention to
the diet, which should be nutritious but not sti-
mulating, carriage exercise, pure air, and ab-
stinence, as much as possible, from harassing
and anxious occupations, will sometimes, for
years,, prolong the patient's life ; but where the
swellings are of many months continuance, little
is to be expected except relief. Even here, life may
be prolonged for a considerable time, under the
most unfavourable circumstances, among the opu-
lent. Not so with the poorer class of patients,
in whom, in this country, intemperance has been
the most active cause of their malady : when re-
lieved of the fluid, which they consider to be the
disease, they speedily return to spirit-drinking ;
and if there be yet power in the system to se-
crete a sufficient quantity of fluid, they are again
affected by their former swellings.
It sometimes happens that after a long and very
unsatisfactory course of treatment, with little
effect in reducing the swellings, and thus re-
lieving the oppression of the patient, the fluid,
after the administration of some trifling remedy,
begins suddenly to subside, with a rapidity equally
astonishing and cheering to the patient: his at-
tention being always fixed upon the dropsy, the
symptom of the disease, he feels delighted at
getting rid of what he considers to be the whole
Such subsidence of the effusion in dropsy, un-
preceded by a gradually increased flow of urine,
or by the use of remedies calculated to produce
evacuations, and which by being administered
during a long period, hinder, at least for a time,
the re-collection of the fluid, is a very fatal symp-
tom; the vital powers are no longer sufficiently
strong to afford relief to the obstructed circula-
tion, secretion from the smaller and more minute
vessels no longer relieves the labouring heart. In
several cases which have fallen under my observa-
tion, the patient has never rallied after this sudden
subsidence of the effusion beyond a month : but
I have heard of life being prolonged somewhat
longer. A case of this kind is to be found in
the experience of the late Dr. Parry, of Bath*.
In the hospital I have had several opportunities
of pointing this out to the pupils. It is an addi-
tional proof that dropsy is only a symptom., and
for the time a relief: if the relief can no longer
be afforded, from the diminished vital powers of
the patient, he sinks, either apparently quite
w 7 orn out, or from the rupture of a vessel within
some important viscus — as the stomach, lungs,
* * See Dr. Parry's Posthumous Works, page 191, vol. i.
CASES OF ANASARCA OCCURRING WITHOUT OR-
GANIC DISEASE OF AN INTERNAL ORGAN—
1 . From Cold applied to the Body.
2. After Eruptive Diseases, especially Scarlatina.
3. From Debility in young Females, with Suppression
of the Catamenia, or succeeding to very large
Discharges of Blood after Child-birth, or from
The first case, dropsy from sudden impression
of cold, is not of very frequent occurrence. Cold
and wet acting suddenly, or for a length of
time, on the surface of the body, more frequently
produce inflammation of internal viscera, as of
the bowels or lungs, or diarrhoea ; but in some
cases, after sudden exposure to cold and wet, the
whole cellular membrane of the body becomes in-
filtrated, the swelling is hard and tense, the pulse
hard, the urine very scanty and incoagulable* by
heat or acids, the heart beats without symptoms of
* This is generally the case, but in some instances the urine
coagulates slightly, a symptom which disappears by the treat-
ment which relieves the dropsy. The coagulability of the urine
organic disease, though its action is increased, the
bowels are costive, the effect likewise follows very
rapidly on the cause applied ; the patient's health
has been good. There is in this state a general
feverish excitement ; the vessels of the skin,
over the whole surface of the body, secrete
serum, and the mucous membrane is deprived
of the natural secretion which these vessels pour
out in a state of health.
The indications of cure are to diminish in-
creased action, and to restore the secretions, espe-
cially those of the mucous membrane of the
bowels, both as revulsive and because of the
great sympathy which exists between the mem-
brane which covers, and the membrane which
lines, the viscera of the body.
The patient should immediately be bled, and
the blood drawn in such cases is almost invari-
ably, in my experience, buffed and cupped. The
next most important remedy for inflammation,
calomel and opium, should be resorted to ; three
grains of the former, and one of the latter, being
given morning and evening, and a saline draught
three or four times in the day : every second
morning the bowels should be freely opened with
in such cases has not been accompanied by alteration in the
specific gravity of this secretion, as in cases where the struc-
ture of the kidney is diseased.
senna and crystals of tartar ; two ounces of the
former dissolving about two drachms of the latter.
The cure of this form of disease will generally be
perfected in about ten days; but the patient
should not be dismissed, or exposed to the air,
thus early, but, as a matter of precaution, retained
in the hospital, or confined to the house, a few
The pathology* of the anasarca which suc-
ceeds scarlet fever is not well understood"}*.
That it is seldom fatal I am fully convinced,
notwithstanding the observations of De Haen
and othersj, and by comparing epidemics with
those of former years, it appears to be far less
frequent than formerly, as a consequence of
Various also have been the opinions of the
* We need scarcely proceed further, to demonstrate the
truth of this observation, than the opinion of Dr. Frank: —
" Cette hydropisie aigu'e peut dependre d'un etat inflam-
matoire manifeste, reliquat de la scarlatine, de la debilite\, ou
elle laisse dans Peconomie de Pirritabilite excessive du
sy steme lymphatique, et ineme de l'etat spasmodique de la peau ;
enfin, des saburres ; mais le plus souvent de la suppression
la transpiration."— P. Frank, Traite de la Pratique de Mede-
cine, torn. ii. page 661.
-j- Ex hoc consectareo plures morruntur quam ex morbo
primacco. — De Meza, torn. i. 59.
\ Plenciz and others.
treatment to prevent so unsightly and protracted
a disease. The French and Italian physicians
attribute its origin to the impression of cold air
on the surface, and religiously keep the patient
secluded in a closed apartment for forty days :
should dropsy supervene, it is invariably attri-
buted to some too slight observance of this rule.
The cold practice in this disease, universally
pursued in Britain, and which is rarely followed
hy anasarca, is the best answer to such an expla-
nation ; the same may be said of the opinions
which attribute this form of disease exclusively
Almost all eruptive diseases are followed by a
diarrhoea*, supposing a mild case little interfered
with by remedies. Small-pox, measles, and scar-
latina, frequently conclude with an attack of this
nature. It appears to me that this points out
the real condition of the disease: where saline
purgatives are freely used throughout the dis-
ease, the means are effected by which nature
terminates the cure. I have seldom, if ever, seen
the anasarca supervene where this class of re-
* It is remarkable also, that an habitual diarrhoea suppressed
will often be succeeded by anasarca. Several cases are re-
lated in Portal's work Sur VHydropisie.
medies was freely used, especially towards the
decline of the disease.
There is a passage in the work of the late
Dr. Hamilton, of Edinburgh*, on this subject,
very striking, and which I have seen fully borne
out in observations in various hospitals both at
home and abroad. Now French and Italian
physicians, as it is well known, employ purgative
medicines in such diseases very sparingly; confin-
ing themselves to the use of enemata, or the
mildest purgatives : hence, in my opinion, the
frequency of anasarca after scarlet fever, com-
pared with the same in this country.
It is fair, however, to say, that these views
do not coincide with those of many old physi-
cians. Dr. Willan says —
" Practitioners in this country have generally
" found the dropsical symptoms yield to diuretics,
" combined with Peruvian bark, preparations of
" iron, or calomel. I do not mean to infer that my
iC countrymen are successful, in this stage of the
* Dr. H. lost three patients in Heriot's Hospital, during an
epidemic of scarlet fever, by the dropsy, which followed the
disease. In the many cases which succeeded these, he em-
< ployed purgatives fully at the decline of the fever, and in no
instance did the dropsy occur.
" disease, by any peculiar practice. If they have
" had more success in the treatment of scarla-
" tina, than physicians on the continent, I would
" ascribe it to the general disuse of bleeding and
"purgatives during the last thirty or forty years,
" within which period gangrene and dropsy have
" been with us much less frequent occurrences
" than formerly. "
The dropsical swellings in every case attended
by Dr. Rush, were removed by doses of calomel
It is remarkable that dropsy by no means
supervenes in proportion to the severity of the
disease. A very slight febrile attack is some-
times followed by it ; and I do not remember,
among the very worst cases of a low type, to
have ever seen one terminate in serous effusion.
It is remarkable also that in the celebrated
work of Dr. Fothergill on this disease,, no men-
tion whatever is made of dropsy as a sequela of
scarlatina maligna, in those who escaped the first
severity of the disease.
Though anasarca is by far the most frequent,
and, in my opinion, the least formidable kind of
dropsy which supervenes on scarlatina, ascites,
hydrothorax, and hydrocephalus, also occur. It
is, however, to be remarked, that all these forms
of dropsy are more tractable than in ordinary
cases, because they are not dependent on disease
of structure. I do not here, however, allude to
the occasional occurrence of purulent effusion
from inflammation of the serous membranes of the
chest (empyema) ; happily a rare, but, I believe,
always a fatal disease, when it occurs during the
course or at the conclusion of scarlatina.
The following case is illustrative of two
points in the foregoing observations : that these
effusions are by no means necessarily preceded
by a severe form of scarlatina ; and secondly,
that they are more curable than ordinary cases,
because less frequently connected with structural
disease of internal viscera.
A married woman, aged thirty-six, was ad-
mitted, some years ago, into St. George's Hos-
pital, under my care, with a slight attack of scar-
latina : the efflorescence was bright, continued
three days; the throat was slightly ulcerated ;
and the cuticle desquamated as usual. During
the efflorescence she was sponged with cold
water and vinegar ; the bowels were freely
opened ; first, fomenting gargles, and subse-
quently astringent ones, were used to the throat,
and the case proceeded to convalescence readily.
At the expiration of ten days she appeared to be
quite well, and remained only in tke hospital
as a precaution against taking cold. About the
fourteenth day from the commencement of the
disease, she was suddenly attacked with pain in
the head, loss of speech, followed by paralysis of
the sphincters, dilatation of the pupil of the eye ;
all which symptoms were formed in the course of
a day and night. The pulse was quick and small,
and there could be no doubt of effusion having
taken place into the head. She was ordered to
be bled to sixteen ounces ; two grains of calomel
were put upon the tongue every three hours ;
and a blister applied to the top of the head, and
kept open with mercurial ointment ; half an ounce
of the infusion of digitalis being put down the
throat with a spoon, the intermediate four hours.
Under this treatment she gradually recovered :
first the involuntary discharges were repressed,
consciousness returned, but the faculties of the
mind remained in a very strange state. The
patient was precisely in a similar condition to that
of one who is recovering from a violent concus-
sion of the brain. She understood all that was said
to her, but could not remember the words to
express her answer. Thus, when asked what
o'clock it was, she explained herself by signs,
not being able to remember the words : subse-
quently she used words, single, and unconnected
by articles, so as to express her meaning, but
not in a sentence. By degrees this power of ex-
pression returned \ she was quite well at the end
of a month, and two years afterwards I again
?aw her in perfect health.
Anasarca, after scarlatina, begins generally
from the fourteenth to the eighteenth day after
the commencement of the disease — sometimes
gradually, sometimes within the space of a very
few hours ; the patient is enormously swollen, so
that the eyes are closed ; the countenance white,
shining, and swollen to an enormous extent ; the
secretion of urine of a deep colour, and in very
small quantity. In many instances the urine is
mixed with blood, and in such cases coagulates.
(See a paper by Dr. Wells, in the first vol. of
the Transactions of a Society for the Improve-
ment of Medical and Chirurgical Knowledge.)
There is thirst, a furred tongue, and even, on the
onset, heat of skin • sometimes, but rarely, diffi-
culty of breathing and headache : the integuments
of the abdomen as well as the scrotum, and the
rest of the cellular membrane of the body, are
anasarcous in the highest degree.
If the preceding fever has been slight, and the
forces of the patient little broken, and espe-
cially if it has been thought unnecessary to purge
in the disease, and no diarrhoea has supervened,*
blood-letting" should not be omitted ; the patient
should be freely purged with calomel, followed
by senna, with crystals of tartar, and this re-
peated every alternate day ; and (for it is difficult
with a child to get much medicine taken) a beve-
rage of half an ounce of sp. setheris nitrici in half a
pint or a pint of water, with a small proportion
of syrup, taken in the day.
Sometimes instead of the senna a tea-spoonful
of an electuary composed of jalap two drachms,
supert. potassas half an ounce, honey half an
ounce, may be given in the morning* succeeding 1
the administration of the calomel with the best
But assuming that the little patient is weakly,
that the forces are much broken by previous de-
licate health, and a severe attack of illness, it
will be necessary to have recourse to diuretics —
either the combination of digitalis with a bitter,
or some of the bitter diuretic infusions. The in-
fusion of digitalis and the infusion of gentian
* It is well known that Sydenham recommends V. S. in the -
diarrhoea after measles : the secretion from the vessels of the
skin,, in scarlatina, where this natural evacuation has not oc-
curred,, seems still more to require this remedy.
" Quern et diarrhoea/' says Sydenham, " quam morbillis
cxcipere diximus, vaenesectione panter sanatur."
have been recommended ; and I have seen, added
to this, the best effect from a drachm of the
liquor potassae in every six ounces, composed of
equal parts of infus. digit, and infus. genti-
anae. In a few cases the decoction of the pyrola
umbellata, to every pint of which half a drachm
of the tinct. of lyttee has been added, (two ounces
taken every four hours), has succeeded in reliev-
ing the disease, in a manner very striking to the
In no case, in my experience or observation,,
has success followed on the use of tonics alone.
It is probable that in many of these cases the
use of the vapour bath would be a valuable ad-
junct in promoting the cure, by inducing a more
healthy action of the skin ; but it should by no
means be employed without premising the use of
3. In chlorotic anasarca, or anasarca occurring
after great loss of blood, a functional condition
of the heart occurs not very dissimilar to what
happens when the viscus is itself diseased in its
structure. An enlarged and dilated heart does
not circulate its blood to the extremities ; con-
gestion of the venous system takes place ; a se-
cretion from the minute arteries relieves this con-
dition. Now in chlorosis there is a deficiency of
red blood ; the heart makes up in frequency, in
very severe cases, what it wants in force, (the
same occurs after great loss of blood — hence what
is called the hemorrhagic pulse,) and the blood
again shews a disposition to stagnate in the right
side of the heart ; the ankles and legs swell, the
face is puffy and white ; in slight cases the pulse
is languid ; in severe ones, as we have said, rapid
and very weak ; there is terrible palpitation on
ascending a stair; the pulsation is communi-
cated to the jugular veins, and there is much
headache : but the treatment is widely different
from that necessary in a case of organic disease ;
the patient's strength in this instance must be
built up, the injured organ is not be relieved
from its oppression by evacuants, but stimulated
gradually to circulate the blood more regularly,
while nutrition affords this fluid of its natural
and stimulating quality.
That physician is the best in this instance who
can introduce steel into the system without ex-
citing fever ; in severe cases, however, the patient
will bear only the very mildest preparations.
The ammoniated tincture, given in the dose of
half a drachm to one drachm several times in the
day, will be generally borne; when, however,
it produces much headache, the cure should be
commenced by ammonia, aether, or the foetid
gums ;* after a short time steel will be borne,
and in another week, the most effectual, in my
experience, of all the preparations of steel, the
mist, ferri comp. will be taken in the dose of an
ounce, gradually increased to two ounces, twice
in the day, with the most decided benefit. To
this must be added, if possible, horseback ex-
ercise, and pure dry air ; first the lightest, and
then the most nutritious animal food should be
administeredf : in this way all the symptoms will
gradually disappear ; the oedema first, and then the
difficulty of breathing ; the palpitation, so long
felt and so alarming, will occur but seldom, and
finally not at all. The catamenia will be re-
gular, the pain in the left hypochondrium (some-
times in both hypochondria) will be no longer
troublesome, and complete recovery established.
Yet such a course as this, where the anasarca
arises from an enlarged and dilated heart, would
undoubtedly destroy the patient : fortunately,
* R Sp. Aramon. Succin. ttlxvj.
Mist. Camphorse, 3iss. M.
Ft. haustus bis terve in die sumend.
R. Sp. Amnion, foetid, ttjxvj.
Mist. ( amphora;, oiss. M.
•j- The bowels should be kept open with the aloes and myrrh
pill, or equal parts of ext. colocynth c. and pil. galbani comp.
generally speaking*, the diseases are not frequent
at the same age, chlorotic anasarca being exclu-
sively a disease of youth, and anasarca after great
evacuations, following on a well-known and
ascertained cause; while anasarca from passive
diseases of the structure of the heart is usually
an occurrence at a later period of life, and its ex-
citing causes, as fright — intemperance, anxiety,
or excessive fatigue — are also pretty generally
ANASARCA FROM DISEASE OF THE KIDNEYS.
That the kidneys are frequently diseased, as a
cause of dropsy, is a modern discovery, which
we owe to the patient investigation and sagacity
of Dr. Richard Bright; and subsequent autho-
rities have confirmed the fact, that the disease of
these organs is always accompanied by a greater
or less degree of coagulability of the urine, ac-
cording as a greater or less degree of alteration of
the structure of the kidneys exists — from perfect
granulation, as pointed out by Dr. Bright, to
The specific gravity of the urine is also always
less than in healthy urine, and there is often a
deficiency of urea in it.
The observations of Dr. Bright have been cor-
roborated in an excellent paper by Dr. Chris-
tison, and afterwards by Dr. Gregory, in the
Edinburgh Medical and Surgical Journal ; while
the method of treatment has been more especially
pointed out by Dr. Osborne, of Dublin, in his
recent very able work on Dropsies, principally in
illustration of this form of disease.
Dr. Christison has left little to wish for in his
very complete paper on the symptoms and patho-
logy of this disease ; and states (a fact repeated
by Dr. Gregory) that, in every fatal case in
which coagulability of the urine, with a low
specific gravity, existed before death, the disease
pointed out by Dr. Bright was found to exist, on
the post-mortem examination ; thus fully and
powerfully corroborating the statement of the
latter physician. Dr. Osborne repeats the same
result from his experience ; and in the wards of
St. George's Hospital I have watched this test
during many years; invariably finding, where
cases with coagulable urine and low specific
gravity proved fatal, that the kidneys presented a
fac-simile of the representation given of them in
this disease by Dr. Bright, in his Hospital Reports.
The urine* in this disease is sometimes scanty
* " Of this state (dropsy) deficiency of urine is a usual
but not a constant effect : for I have seen at least ten cases, at
various ages, from fifteen to sixty, of dropsy, chiefly anasarca,
ending in hydrothorax, in which the quantity of urine has spon-
taneously been, from the beginning till two or three days before
death, fully equal to that which was natural : as for example
and high coloured ; but in the worst cases the
urine has been found to be pale and abundant,
while the anasarca was general and to a great
extent. In such cases the disease is very fatal \
and the condition of the kidney, its extensive
disorganization and obstruction visible after
death, explains the reason why anasarca, without
any diminution of the secretion of the urine, was
always looked upon as a condition of disease un-
The cases which have occurred in my prac-
tice, where the urine was abundant and pale
coloured, have all been in young subjects, from
eighteen to twenty-five years of age : three of
these cases occurred to me in the course of last
year : in all of them the kidneys had reached
the highest state of granulation.
The coagulability of the urine after scarlatina,
with admixture of blood, was noticed by Dr.
Wells; and this peculiarity in the secretion
formed a division in Dr. Blackall's work on
Dropsies. That it occurs in dropsies from cold,
in which an inflammatory state of the system
exists, has been remarked, and is relieved by
from two to four pints daily, clear and even so?neli?ties pale,
and yet the patients have all died. Nay, I have never seen a
patient recover under these circumstances of a natural state of
urine." — Parry's Posl/nunous Works, vol. i. p. 192.
ordinary antiphlogistic treatment ; but it exists
also in crises where long-continued organic dis-
ease has broken the vital powers, and where,
though inflammation may have been the cause of
the destruction of the structures in the first in-
stance, no inflammatory action any longer exists,
and has been shewn, in every fatal instance, to
have proceeded fron N disorganization of the
kidney, and of the kidney alone.
There is only one position on which I am in-
clined to differ with the accomplished author of
the Hospital Reports. Where disease of the liver,
heart, and kidneys, exist in the same patients,
Dr. Bright appears to believe that disease of
the kidneys is the primary disease, and the dis-
organization of the other important structures
secondary. It is more clear to me, that the same
cause, the abuse of ardent spirits, or long-continued
and repeated exposure to cold, which has pro-
duced disease in one vise us, has also affected the
others. We know that disease of the liver and of the
heart proceed from intemperance ; and instances
are not wanting of disease of the kidney producing
anasarca arising from this cause, and existing
alone. One of the worst cases I ever saw, of
anasarca with coagulable urine, was in a youth
of nineteen, who had been addicted to the immo-
derate use of spirits, rum principally, and no
other viseus was diseased except the kidneys.
Again, how often do we not find, after hard
drinking, enlargement of the heart and liver,
accompanied by anasarca and ascites, while the
kidneys remain perfectly sound?
About half the cases of dropsy admitted into St.
George's Hospital, in my experience, have coagu-
lable urine : and in about one-third of such of these
cases as have proved fatal, the kidney was the
only viscus diseased : the other two-thirds had
disease of the heart and liver in addition to gra-
nulation of the kidneys. Of those cases of ana-
sarca without coagulable urine which proved
fatal, the heart was invariably greatly enlarged ;
and these were often complicated with ascites
from disease of the liver.
When a patient presents himself for examina-
tion with anasarca of the legs, thighs, and pa-
rietes of the abdomen, of some weeks' duration,
where no disturbance in the motion or regu-
larity of the heart's action is to be perceived,
and on testing the urine by heat, or the addition
of a mineral acid, it coagulates strongly, we may
safely conclude that disease of the kidneys is the
organic cause of the dropsy : if the urine be
scanty and high coloured, it is a relievable case ;
if abundant and pale-coloured, one of deep
anxiety. The skin is singularly pale and dry in
this disease : and Dr. Bright has very fully ex-
emplified the fact, that persons labouring under
it are subject to sudden inflammatory attacks of
various viscera, and even of effusion into the
ventricles of the brain. The principal indications
of cure, then, are to get rid of the dropsy by such
remedies as will alter the morbid condition of the
urine; and, secondly, to remove any inflammatory
attack which may arise in the course of treatment.
Dr. Bright, and subsequently Dr. Osborne *,
have laid great stress on the sympathy which
exists between the skin and the kidneys, and re-
commend every attention to restore the healthy
secretion of this organ. The great relation which
exists between these two secretions has long
been observed, and indeed is obvious to the
most careless observer in the ordinary functions
of health : in disease, the same importance of
the relation is still more obvious, nor can I in-
stance it better than in the words of the cele-
brated Dr. Mead : —
" There is a great harmony between the
kidneys and glands of the skin, so that the hu-
mours brought on the latter easily find a way
* On this point it would be quite unfair to quote single
passages from Dr. Osborne. This physician tell us, and his
evidence is quite worthy of confidence, that one-fourth of the
cases, such as we have described, succeeded under his plan,
" which never failed in removing this kind of general dropsy,
whenever the surface of the body was restored to a per-
spiring state.'* — See Osborne on Dropsies, p. 45.
The whole work is well worthy an attentive perusal.
through the former, and are carried off by urine ;
and on the other hand, when the kidneys have
failed in the performance of their functions, an
urinous humour perspires through the cuticular
Dr. Wells cured three cases out of five, of ana-
sarca with coagulable urine, with cantharides ;
and Dr. Mead recommends them in lepra,, from
their diuretic property. Dr. Bright states that he
has succeeded with the cream of tartar in several
instances, and I have found this medicine far
more useful than any other in dropsy from
disease of the kidney ; but looking" to the func-
tions of the skin, I have employed also the
vapour bath, using this remedy on alternate days.
The perspiration excited by the vapour bath is
excessive, and its use should be graduated to the
patient's strength. I have found this remedy
far superior to any internal one known to pro-
duce diaphoresis. Where there is pain in the
lumbar region, as not unfrequently occurs in an
aggravated form of the disease, cupping is very
useful, and every intercurrent inflammatory dis-
ease I have been in the habit of treating exactly
as if no dropsy had existed, according to the
symptoms and locality — blisters only being ex-
cepted, from their being often followed by ery-
sipelas, and even sloughing.
* Mead : Medica Sacra.
I have been careful, on a subject so extensive
as the present, not to overload the observations
I wish to lay before the profession with cases;
my opinion is formed from the habitual observa-
tion of them j but, except to illustrate a particular
point, I have been desirous of leaving results to
be considered alone.
The following case of dropsy from disease of the
kidney will best illustrate the mode of practice
which I have found successful : —
B. C, aet. 30, was admitted into St. George's
Hospital under my care, March 80th in this
year : she laboured under anasarca of six months*
duration, affecting the lower extremities, inte-
guments of the abdomen, and face. The heart
and respiratory organs were natural in their
action : pulse 84, and not weak ; the bowels
The bowels were opened by a dose of calomel,
followed by senna and crystals of tartar, and she
was ordered to be bled.
The blood drawn shewed no inflammatory
crust : the urine was of very low specific gravity,
and coagulated into a solid mass by acids and
heat ; it was very scanty and high coloured.
31st. She was ordered the vapour bath every
alternate day ; was cupped on the loins ; and the
diuretic mixture of infus. digitalis, liq. oxym.
hydr., and tinct. canth. ordered, but it disagreed,
making her feel sick : an ounce of supertartrate
potass was ordered to be taken daily in solution.
On the 6th, much perspiration was found to
be produced by the bath. On the 12th, ana-
sarca was greatly diminished, urine increased
in quantity, and general health greatly improved.
19th, The urine coagulated very slightly, either
by acids or heat. 23d and 24th, Much pain was
complained of in the head and left side, with
spasmodic twitchings of the muscles ; the pulse
was strong, and the skin warm : she was ordered
to be bled, and calomel grs. ij.. and opium gr. §,
given every third hour. The blood drawn was
buffed and cupped.
On the 28th, all these symptoms having dis-
appeared,, the mercury was omitted, and the use
of the cream of tartar resumed, with the bath.
30th. She was without pain ; the urine was
pale, abundant, and alkaline : pulse 80, and not
strong ; the bath very agreeable to her.
She appeared quite well, when, on the J 3th of
May, another inflammatory attack, apparently
affecting the kidneys and bladder, took place :
she was bled, (the blood was inflamed,) and ca-
lomel and opium prescribed for two days : when
the symptoms having* disappeared, she resumed
the use of the bath and cream of tartar.
On the 26th the dropsy had entirely disap-
peared, the urine was natural in quantity and
quality : she remained in the house until the 7th
of June,, during" which time her appetite and
the secretion of urine were perfectly natural,
and she had regained her strength.
ASCITES, OR DROPSY OF THE ABDOMEN.
Ascites, or dropsy of the peritoneal cavity, may
arise, in an inferior degree, in either of the above-
mentioned conditions of disease, in conjunction
with anasarca from disease of the heart or disease
of the kidneys. I believe, however, that where the
kidneys alone are diseased as a cause of dropsy,
ascites is not generally perceived, (such has been
my experience) ; but any apparently increased
bulk of the abdomen arises from anasarca (infil-
tration of fluid) of the cellular membrane of the
Where the heart is alone diseased, the collec-
tion of fluid occasionally occurs in the peritoneal
cavity, but it is subordinate, from its smaller quan-
tity, in importance to that contained in the cellu-
lar membrane. The circulation in the abdomen
is peculiar : the greater quantity is expended in
forming the important secretion of bile from the
vena portee, and the remainder only is returned
by the hepatic veins to the right side of the
heart. The obstruction therefore to the heart's
action, arising* from enlargement or dispropor-
tionate dilatation of the cavities of the organ,
will affect the venous system in the abdomen far
less than throughout the whole body : hence it
is that anasarca is the most common form of
dropsy attendant on disease of the heart, and
where this important viscus is alone diseased,
ascites scarcely appears.
The principal cause of ascites, or dropsy of the
abdomen, is disease of the liver ; and much spe-
culation, especially of late years, has been em-
ployed, to demonstrate that the disease of the
liver, which precedes ascites, is always inflam-
mation, and that it principally affects the serous
Formerly, enlargement of the liver was con-
sidered as the cause of ascites, and the mecha-
nical bulk of the viscus pressing on the vena
portae as the cause of obstruction to the due cir-
culation of the secreting fluid • hence thrown
back on the capillary veins, and causing a corre-
sponding exhalation of fluid from the exhalent
arteries, to relieve the congested vessels, and
maintain the balance of the circulation.
Such a condition, however, does not occur,
except very rarely, as a cause of dropsy of the
abdomen, and then only when the viscus is not
simply enlarged, but indurated. Where the
liver is enlarged by depositions of matter of a
malignant nature, and known under the name
of encephaloid tubercles, its size will often oc-
cupy the whole abdomen, without any ascites
being present. It has occurred to me to see a
case, in which the liver measured sixteen inches
in length and fourteen in breadth, occupying the
w hole of the superficies of the abdominal cavity,
excepting a small notch or space in the left iliac
region, without any effusion of fluid whatsoever;
there being, as it appeared, a sufficient interstitial
quantity of the usual structure of the liver to
permit the circulation necessary for its functions
to be carried on. The most frequent appearance
of disease of the liver, and that which is most ge-
nerally connected with ascites, is characterized by
diminution of the bulk of the viscus : the liver is
about one-half its natural size, very hard, and
with the sharp edge, so characteristic of it in a
state of health, blunt and rounded. In post-
mortem examinations, instead of finding it pro-
truding into the belly, we seek for it under the
ribs in the right hypochondrium, and find it
there drawn up, as it would seem, from its dimi-
nished size. The peritoneal coat is in such case
most frequently found thickened : this not un-
usually takes place in parts; and this partial
thickening gives to the viscus the appearance of
being* puckered, not very unlike the lobulated
structure of the calf's kidney. On cutting into
these portions, the viscus itself does not present
corresponding depressions, but the appearance
arises from the membrane having been thickened
in parts. Occasionally the whole peritoneal coat
is thickened, of a milky white colour, and the
viscus beneath contracted, extremely hard to the
knife, and presenting a round almost globular
mass when removed from the body.
The consequence of this change is, the uniform
pressure upon and obstruction of the minute and
secreting branches of the vena portce : such an
obstruction naturally throws back the blood upon
the trunk of the vein * the capillary veins are
congested, and the capillary arteries secrete
fluid — not a transudation from their coats, as
was conceived, but a secretion resembling the
serum of the blood.
This thickening of the peritoneal coat has
made some authors suppose that inflammation of
this covering alone is sufficient to produce the
disease, and that it is never found where such
marks of inflammatory action are absent : hence
that dropsy is necessarily the result of inflamma-
tion, and the deduction to be drawn is, that it
is to be combated essentially by antiphlogistic
But this is a mistake : inflammation of the
peritoneal covering" of the liver, in common with
other parts of the peritoneum, may exist to a
great extent without dropsical effusion : and
there is another condition of disease of the liver
in which the peritoneal coat remains uninjured,
where dropsy is equally the consequence, because
uniform obstruction is presented to the extreme
branches of the vena portae.
In this instance, the secreting structure of the
liver is nearly obstructed by the deposition of
reddish-white substance, by some believed to be
lymph, and the effect of inflammation, by others
supposed to be cholesterine ; but in either case,
on a section of the liver, the whole seems to be
made up of rounded masses, which, in some in-
stances, can be separated from the cellular mem-
brane which connects them, but the change is
uniform throughout the whole mass. In many
such cases the peritoneal coat is quite clear and
transparent, proving that causes exist, indepen-
dent of its thickening, to produce such an ob-
struction to the progress of the blood, as to act
as the proximate cause of dropsy.
But it will be asked, how does this explanation
agree with the cases in which the structure of
the liver is wholly obliterated — in which the well-
known secreting* parenchyma is changed into
a fatty mass, or of a very pale yellow colour, or
almost entirely composed of encephaloid tuber-
cles, and yet there is no dropsy present ?
That such cases have occurred there can be
no doubt ; and it appears to me to be accounted
for by the alteration in the circulating fluid itself :
there is a degeneration of the whole body, the
arteries do not secrete fluid, in order to keep
up the balance of the circulation, impeded by
the disease of the viscus ; but both solids and
fluids undergo a degree of degeneration, and
the whole system tends to decay. The ap-
pearance of persons labouring under this form
of disease confirms this idea; the countenance
is of a waxy yellow colour ; no red blood ap-
pears circulating on the surface ; the principal
ailment complained of is excessive weakness,
sinking, often without any local pain ; the pulse
is weak, and about a hundred in a minute ; the
patient is emaciated, and the muscles have lost
their firmness and colour ; in blood drawn from
the arm, the red particles are scanty, and the fibrin
scarcely adheres ; a weakened state of the nutritive
fluid, adapted to the weakened state of parts
which act in the function of secretion, and both
tending to the undoubted death of the patient.
I shall proceed, then, to speak of the most fre-
quent, most obvious, and most invincible form of
ascites, which arises, as has been before stated,
from a contracted state of the liver, with a thick-
ened peritoneal coat, or from a universal altera-
tion of the secreting structure of the viscus, by
the deposition of reddish-white matter; by some
considered to be coagulable lymph, by others
believed to be cholesterine, the peritoneal coat
retaining in this case its transparent and healthy
character. The first condition is undoubtedly
produced by intemperance, especially in the use
of spirits. The second case is less frequent, and
I am inclined to believe often arises from (at least
in three instances it could be traced to) indul-
gence in the use of opium.
The external appearance of a person labouring
under ascites from either of these causes is in strik-
ing contrast with those cases of anasarca which arise
from disease of the heart. When some induration
of the liver accompanies disease of the heart, both
ascites and anasarca are present, but the abdo-
minal effusion is small in quantity, compared
with that which takes place in the cases I am
attempting to describe : in the former, the in-
crease of bulk is principally owing to infiltration
of the cellular membrane connecting the muscles
of the abdomen ; in the second, these muscles
are wasted, the fat absorbed, the distended ab-
domen is tense in every part, the swollen veins give
to the whole a bluish appearance, while the hands
and arms are wasted, the features drawn in and
haggard, presenting the appearance of what has
been termed " facies hippocratica j" the legs
are also often wasted, and indeed always, early
in the disease, but at length the pressure of the
immense body of fluid in the pelvis prevents the
return of blood in the iliac veins, and the lower
extremities become anasarcous. The pulse is
quick and feeble ; the tongue red, and rough with
prominent papillae, and sometimes aphthous ; the
urine is very scanty, and deposits a pink sedi-
ment, like the finest rouge ; the thirst is insup-
portable ; and the alvine excretions scanty and
ill-coloured,, the bowels being sometimes difficult
to move, at others affected with diarrhoea.
To such a condition of disease it would be
impossible to propose a cure, unless our art ena-
bled us to repair the greatest extent of visceral
disorganization. When the effusion is recent,
indeed, advantage is occasionally derived from
rubbing in mercury over the whole abdomen ; a
drachm of the liniment hydrarg. may be used for
this purpose, rubbed in morning and evening ;
three grains of calomel, with double the quantity
of rhubarb, being given every alternate night,
and followed by a senna draught, with crystals
of tartar, in the morning.
It is to this condition of disease, that on the
continent, and indeed in our own country, the
infusion, and decoction, and extract of the dande-
lion, have been thought peculiarly well adapted
as a deobstruent.
It has, especially in Germany, been considered
of great efficacy • and was prescribed by Zimmer-
man for the dropsy, which terminated the life of
the great Frederick of Prussia. Had the philo-
sopher persuaded the monarch to abstain from
eating enormous quantities of most indigestible
food, he might, perhaps, have succeeded in re-
tarding the disease, and the virtues of the taraxa-
cum have been still higher extolled. I have seen
this medicine prescribed in hospitals, in very
large doses, in extract; I have seen it, both
abroad and at home, given in decoction and in-
fusion, without ever being able to trace any ob-
vious effect from its use beyond slight diuresis,
or occasionally, when in large quantities, relaxa-
tion of the bowels.
The patients labouring under this form of
disease are scarcely able to bear the elaterium :
the injury to the principal organ of nutrition,
and the weakened frame, sustain ill the violent
effects of this medicine, and the patient's chief
comfort is derived from the use of diuretic drinks,
- especially nitre in solution, which relieves the
craving thirst more than any other remedy.
The action of other diuretic remedies will be
found described in the former part of the work :
it is unnecessary to repeat the observations here.
Where the disease is very far advanced, I have
occasionally (in one or two instances) seen tonics
do more on the intermediate days, when the pur-
gative formerly mentioned is not given, than
any of the ordinary hydropic remedies. Two
grains of the sulphate of quinine dissolved in two
ounces of water, with a few drops of diluted
sulphuric acid, and rendered more palatable to
the stomach by the addition of a drachm of
the tinct. cardamomi c, have appeared for
a few weeks to work wonders, and to impart
at least to the patient that hope without which
his state would be even less supportable than
it was. In such cases, also, some relief is ob-
tained by sustaining the patient's strength ; thus
enabling him, as it were, to support life under
extensive disease of structure which no known
remedies will relieve. The preparations of iron
are consequently occasionally used with success.
The muriate of iron acts also in such cases some-
times as a powerful diuretic. Ten minims of the
tincture may be given thrice daily in infusion of
When the collection of fluid has existed during
some weeks, the mind of the practitioner is di-
rected to the immediate relief of the distention,
by tapping. There is some little difference of
opinion in the profession, as to the best time for
performing the operation ; some postponing it
until a fair trial has been given to the operation
of medicine, others thinking that the cure will
be expedited by performing the operation as
soon as the fluid has become very abundant.
The arguments brought forward for this method
of proceeding are, — 1st, that by drawing off the
fluid the organic disease may be ascertained.
2dly, that it is well known that diuretic medicines
producing little effect while the distension is ex-
cessive, become extremely efficient as soon as the
fluid is evacuated : of this fact there is no doubt.
It has occurred to me to see patients, the night
succeeding the operation, void several pints of
urine under the use of the same remedies which
had failed in producing as many ounces previous
Still in such cases I am not inclined to advise
it until purging, with neutral salts, and mercurial
* P. Frank, though recognizing the fact, still objects to
te Mais les cas rares ne doivent pas servir de base aux indi-
cations. Si la paracentese augmente frequemment la secretion
des urines, souvent elle n'exerce sur elle aucune influence
frictions, have been tried. It is not unaccom-
panied with danger from peritoneal inflamma-
tion ; and, as is well known, the necessity for
having- recourse to it speedily recurs.
Where the liver has been contracted during* a
long period, has a puckered peritoneal coat, or
that membrane is thickened like semi-transparent
horn, its sharp edge having entirely disappeared,
or where the secreting vessels are uniformly
obstructed, the fluid drawn off is quite limpid,
and enormous in quantity.
If clear serum, but deeply tinged with blood,
follow the introduction of the trochar, we may be
certain that a malignant growth of considerable
size, (so large as to press upon the blood-vessels)
often attached to the liver or ovarium, is the
cause of the peritoneal dropsy. I am not to be
understood to say, that when a large morbid
growth in the abdomen, of the kind termed fun-
goid or malignant, proves fatal, accompanied by
dropsy, that the serum is always bloody ; but
that this bloody serum, when it does occur, al- -
ways depends on such morbid growth. In many
cases in the hospital I have seen this remark veri-
fied, so that I believe it to be strictly correct.
There are two other principal appearances of
the fluid drawn off in abdominal dropsy by the
operation of tapping : it is often of a pale yellow
colour, more or less tinged with bile, and on
standing quickly coagulates.
The last appearance is from cases in which the
collection of fluid is not large, and principally
from patients of an early age and strumous
habit of body. It is the colour and consistence
of whey, with shreds of lymph floating in it ;
and is undoubtedly the product of inflammatory
action, modified by the constitutional disease we
have mentioned, for where acute inflammation
of the peritoneum terminates in similar effusion,
it uniformly proves fatal : it is the product, there-
fore, of a slower inflammatory action than in
Those who advocate inflammation as the cause
of dropsy in every case, consider that these con-
ditions of the fluid are produced by different
degrees only of that morbid process, varying from
acute through various subacute stages of inflam-
In the last kind of effusion which we were
considering, inflammation undoubtedly appears
to have been present. In the other cases, inflam-
mation may have been and probably has been the
cause of the thickening, and hardening, and con-
traction of the liver, but the effusion is a conse-
quence of this alteration of structure already
produced : and in cases of serum effused from
the pressure of malignant tumours, these peculiar
formations are, I believe, traced by no one to
true inflammatory action at their commencement
or during' any part of their growth.
In speaking of anasarca I remarked that, in
very severe cases, the sudden subsidence of the
effusion was an occurrence of very dangerous
import. The same applies to the sudden disap-
pearance of ascites after the affection of the liver
of which we are speaking, but the phenomena
are different : the disappearance of the fluid is
preceded by frequent and almost uncontrollable
vomiting ; or if the water has been drawn off by
tapping, and does not again collect, violent pains
in the bowels occur, accompanied by diarrhoea,
which is at last often not to be restrained by any
of the usual remedies. Where such cases have
occurred, I have anxiously looked, after death,
for some cause to explain these remarkable
symptoms. Avery unusual appearance has pre-
sented itself : the intestines are of a deep leaden
blue colour throughout their whole extent, and
the omentum of the same colour; the perito-
neal coat covering the intestines thickened and
opaque. Sometimes shreds of lymph, of no very
recent formation, adhere to the convolutions, but
in general the whole peritoneal covering of the
intestines is only thickened equally throughout,
and of this blue colour. I have known the pain
and diarrhoea immediately succeed the disappear-
ance of the fluid, and last during" several weeks, its
severity little mitigated by remedies, and I have
been in the habit of pointing out its unusually
fatal import to the pupils. In every case in
which such symptoms have preceded the termi-
nation of the patient's life, the ascites has been
occasioned by the peculiar, hardened, and con-
tracted state of the liver, which I have attempted
In speaking of the several forms of ascites
which arise from a contracted and hardened
liver, I am not to be understood to overlook that
effusion of fluid into the abdominal cavity which
succeeds to enlarged and hardened liver and
spleen. So long as the liver is soft in its tex-
ture, and a sufficient quantity of healthy paren-
' chyma is left for the peculiar circulation in this
viscus, it may be enlarged so as to occupy the
whole abdomen, without being the cause of
ascites : but if the enlargement be accompanied
by hardness, effusion (less indeed in degree than
the former case, and more tractable by medical
art) will take place.
This is especially the case in ascites which
arises after enlargement of the liver and spleen,
from repeated attacks of ague. During' the
cold stage of an intermittent, the blood recedes
from the surface of the body into the viscera,
a hot or inflammatory stage succeeds, and the
repetition of these paroxysms is followed by
enlargement of the viscera before mentioned ; '
and after repeated attacks, by ascites, or in its
place, frequent and sometimes fatal epistaxis, -
or vomiting of blood. In such cases the
well-known cause, and indeed the enlargement
of the viscera, which may be felt through the
integuments of the abdomen, render the case
From the time of Sydenham*, purging at the
conclusion of ague has been insisted on ; and by 1
thus drawing off from the enlarged and dis-
tended vessels, the increased size of the organ is
prevented. Where such means are not adopted,
or the unhappy patients are obliged to be exposed
to the noxious exhalations which occasion repeated
attacks of thedisease — as in the Maremma and the
Pontine marshes in Italy — the thin and haggard
countenances, the swelled, protuberant belly, and
* " Sublato morbo aeger sedulo purgandus est; incredibile
enim dictu, quanta morborum vis ex purgationis defectu post
febres autumnales subnascatur. Miror autem hoc a media's
minus caveri, minus etiam admoneri." — Sydenhami Opera }
art. Febr, Interm.
absence of nutrition, point out this disease in
characters not to be mistaken.
Fortunately, except under very aggravated
circumstances, the effusion and its cause are re-
moved, and the patient permanently cured, un-
less constantly exposed to the miasmata. Mer-
curial frictions have often a most extraordinary
effect in this disease, reducing the swellings, and
from their diuretic power carrying off the effused
fluid at the same time. To these saline purga-
tives should be added ; and it is remarkable that
mineral waters possessing purgative qualities are
often found in the neighbourhood of marshy dis-
tricts, affording the ready means of relieving the
diseases engendered by a sojourn in these un-
healthy regions. The waters of St. Filippo, in
Tuscany, are annually resorted to for this pur-
pose : they resemble in some measure the waters
of Harrowgate, often drunk in our country, to
relieve the chronic diseases of the liver, con-
tracted during a residence in India. The waters
also of Monte Catini, near Pisa, are celebrated
also in that country, whose marshy districts
abound with ague, for the cure of visceral ob-
The practice also of letting fall a column of
hot water on the affected part, under the name
of douche, affords a very effectual method of '
reducing" the swellings of the viscera. This prac-
tice in France and Italy, in such cases, is almost ■
Modern discoveries also have afforded a most
powerful agent in reducing" these swellings,
when of long standing*, in the hydriodate of
potass. Two or three grains of this salt, taken,
dissolved in two or three ounces of water, twice
daily, will sometimes succeed when other remedies
fail : under its use the patient's strength and
appetite will return, while the dropsical effusion
subsides gradually, with an increased and limpid
flow of urine. Of course, if the enlarged viscera
be painful to the touch, it will be advisable to
apply leeches repeatedly, before having recourse
either to mercurial friction or the use of the hy-
driodate of potass. Where mineral waters cannot
be obtained, the best saline medicines are the tar-
trate or supertartrate of potass, or the Rochelle
salt (tart. pot. et sodee), in the dose of from half an
ounce to six drachms, every morning, dissolved
in half a pint of water.
The use of bark in the cure of ague suggested
to many authors the continuance of its employ- -
ment in the visceral obstructions consequent on
frequent attacks of that disease ; but physicians
who entertained such opinions were almost uni- •
formly obliged to mix with this medicine some
evacuant, generally a diuretic. It will appear
by the following opinion of Frank, that bark is
ineffectual, even in the hands of the advocates
for debility, without such an addition : —
"Thus, even in the dropsy which succeeds to
intermittent fever, when the patient derives no
advantage from the bark, or cannot bear it, we
add gentle diuretics to this medicine, and gra-
dually increase them by the addition of the
more powerful ones : we first combine cream
of tartar and juice of elder-berries, afterwards
with oxymel scillae in form of electuary. This
combination produces often the effect which
cannot be expected from bark alone. In this
state of sensibility, bark is often less efficacious
than bitters, such as the lesser centaury, the
trifolium fibrinum, absinthium, quassia, together
with the root of the ononis spinosa, whose diu-
retic properties we have often experienced, or
with the berries of juniper*."
* Frank, Medeoine Pratique, Retentions Aqueuses, p. 240.
ASCITES FROM DISEASE OF THE PERITONEUM.
Tcberculated accretion of the peritoneum has
been so ably described by Dr. Baron,, of Chel-
tenham, that I should not here speak of it, ex-
cept on account of the ascites, with which it is
often accompanied. The disease, where it proves
fatal early, consists of a pearly thickening of the
peritoneum, the membrane being* pushed up by
numerous eminences, or tubercles deposited on
the cellular side of the serous membrane : in
more chronic cases, large masses of thick cheesy-
looking matter are deposited on the cellular side of
the omentum, sometimes distending it, like a
bag, into an unequal globular tumour ; at others,
into a thick flat mass, compressing the intestines
like a pad. In this form of disease there is often
vomiting, and vomiting of a peculiar character;
it is of a deep leek-green colour ; precisely the
colour of the beautiful fluor spar, found at Alston
in Cumberland ; sometimes varying 1 to purple.
I am not to be supposed to say that this peculiar
vomiting" occurs in every form of this disease ;
but where it does occur, in every instance the
disease so faithfully described by Dr. Baron has
presented itself on the examination of the body.
My attention was first called, about thirteen
years ago, to this circumstance, in a very remark-
able case, at Guy's Hospital, under the care of
Dr. Cholmeley. That accomplished pathologist
stated at the time, that whenever he had seen
this peculiar vomiting, the post-mortem appear-
ances were those of the disease alluded to, and
thus it proved ; and in consequence of this veri-
fication I have been enabled, in several instances
where the symptoms were obscure, to determine,
from the presence of this peculiar vomiting, the
nature of the disease; and I do not remember a
single instance in which the event did not con-
firm the diagnosis. At the same time, I do not
remember to have seen this symptom present
when the disease was accompanied with ascites,
the evacuation preventing., probably, the serous
The dropsy which accompanies this disease is
always more scanty than that which is the con-
sequence of disease of the liver; sometimes only
a few pints, and seldom more than two gallons,
are poured out : indeed, the latter quantity is, as
far as my experience goes, the utmost limit of
effusion in such cases.
It is more common in young people than in
old, and in females than in males.
The dropsical effusion is often mixed with
shreds of lymph, and is moreorless whey-coloured,
from the presence, doubtless, of low inflamma-
tory action, and it more frequently accompanies
the universal thickening' of the peritoneal cover-
ing of the bowels, than where accretion of the
omentum forms the mass of disease : after death
the small intestines are glued together, and more
than once I have seen the whole taken out toge-
ther after death, in one globular mass, by passing
a ligature round the root of the mesentery.
The pulse in such cases is weak and quick ;
the features pinched and sharp, and the tongue
red and glazed, as if a hot iron had touched it ;
sometimes of still deeper red colour, with patches
of aphthae. There is always a sense of weight and
distension in the abdomen, even where no ascites
Mercury administered internally is rarely at-
tended, in my opinion, with advantage ; nor does
powerful purgative medicine seem to produce
any really good effect, and it is apt to induce vo-
miting, which is much to be dreaded. The
disease occurs in strumous constitutions, and ap-
pears to arise from inflammation, modified by
that constitutional disease, as intractable as chro-
nic strumous ophthalmia, or chronic scrofulous
disease of the joints, or the slow inflammation
and suppuration of lymphatic glands, are, by
I have observed that where effusion takes
place, it often arises early in the disease 5 whereas,
where the disease is fully established, and the pro-
longations of the serous membranes are formed
into hard masses, it is more frequently absent,
while peculiar and fatal vomiting relieves the
obstructed circulation ; and hence it is, I think,
that I have seen several young patients rally,
where the dropsy appeared early from this organic
The disease is not so very common as to enable
any one to lay down a general rule, or to speak
positively on the subject : here I only relate the
result of my own experience. Tapping has uni-
formly been followed by bad results, increasing
the low inflammatory action, and tending thus,
perhaps, to exasperate the disease ; at least, I have
never seen a case recover after this operation
has been had recourse to ; and as the collections
of fluid are rarely very great, the urgent desire
of the patient to be relieved from the distension is
not so strong as in effusion into the peritoneal
cavity from other causes.
If, when the physician is consulted, the pain
on pressing the abdomen be severe, one bleeding
from the arm will be necessary, or if the patient
be weakly, a dozen leeches may be applied to
the abdomen : further than this,, antiphlogistic
practice appears to be hurtful, and in many cases
the practitioner is not consulted until the results
of slow inflammation have been established; thus
rendering depletion improper, as weakening the
forces of the patient, without controlling the
action which first produced the disease.
Frictions with the liniment hydrarg., morning
and evening, are often attended with benefit, but
it is on the use of the hydriodate of potass that I
have been accustomed to rely, from finding the
general health recover under its influence, and
the effusion, hardness, and tightness of the ab-
domen, disappear in a remarkable manner. Two
grains of this salt, given in a draught of equal
parts of cinnamon water and common water,
with a little syrup, may be administered for several
weeks, twice in the day, with no other visible effect
than the amendment of the patient's health, or if
any visible effect is produced, it is slight diuresis ;
even during" its employment, a few leeches may
occasionally be applied with advantage where
there is any pain on pressure : if restlessness and
sleeplessness be present, five grains of the ext.
conii may be given with each draught, in the
form of pill.
The bowels in this disease are generally con-
stipated, but the secretions, when obtained, are
often not unhealthy : it is difficult to move them
with colocynth or similar medicines, from the
pain they occasion, or with mercurials, from the
vomiting- which often accompanies, and the de-
bility which succeeds to their use. In such cir-
cumstances the medicine which I have found
best to agree, is the phosphat. sodas, of which half
an ounce or six drachms may be given daily in
a pint of beef tea. It is not disagreeable, and
can sometimes be borne by stomachs which,
from organic disease, reject every thing pre-
sented to them. Whether really these neutral
salts possess a deobstruent power, (as the sulph.
of potass was supposed to have in tabes mesen-
terica), or the good effect is owing to the regular
and long-continued evacuation of the bowels, I
cannot assert, but I can safely recommend them
as a most convenient laxative in the disease I
am commenting upon.
A few months since I attended, with Mr.
Merriman, jun. of Kensington, a young lady,
set. 13, affected with ascites apparently arising
from this disease. Under the plan laid down,
persevered in for several weeks, not only the
effusion disappeared, but the tumours also be-
came imperceptible on minute examination.
Ascites is also sometimes the consequence of
other diseases. Very solid tumours of the ovary,
or enlargement of the ovary, with much of the
structure in the cysts solid, will often, from
pushing upwards the intestines, compress veins
of the venae portae, and produce ascites. It is not
unfrequent to see the introduction of the trochar
followed first by clear serum from the peritoneal
sac, and afterwards by ropy muco-albuminous fluid
from a cyst in the ovarian tumour. In a case in
which Mr. Caesar Hawkins operated, eleven
pints were drawn off from the peritoneum, and
nine from the cyst. In such cases, the recumbent
posture and diuretic remedies will often relieve
the ascites in a remarkable degree, and after a
time the tumour often shifts its place, and the
local pressure is removed.
Some persons, even the great Morgagni himself,
have attributed dropsy, in some cases, to bursting
of the lymphatics, and ascites to bursting of the
thoracic duct. I have carefully examined the
thoracic duct, in many cases of ascites, but never
could detect any alteration except distension in
it and the lymphatics. Neither does simple ob-
struction of glands appear to occasion dropsy,
by pressure on the lymphatic vessels : large col-
lections of diseased glands are found in the axilla,
pelvis, and in the neck, but without dropsy.
The enlargement of the mesenteric glands is
more frequently accompanied by marasmus
than by dropsy : and even when ascites is pre-
sent in combination with this disease, there is
also the slow scrofulous inflammation of the pe-
ritoneum which we have just been describing,
or the glands are so much enlarged as to press
on the trunk of the vena portee.
In the same way, if the glands in the groin or
axilla enlarge in such a manner as to press on
the great veins of the extremities, there will be
oedema below the pressure, but otherwise it is of
daily occurrence to meet with lymphatic glands
of great size and hardness, without any dropsical
effusion : for the tension, redness, and heat,
with slight effusion, occasioned in the neigh-
bouring cellular membrane, by inflammation of
these tumours, cannot be referred to dropsy,
though some writers have imagined that they
saw the first pathological process towards the
formation of dropsy, in this pouring out of fluid
by the capillaries in the vicinity of an inflamed
Ascites does not succeed eruptive diseases as
frequently as anasarca ; and it has never oc-
curred to me to see it alone after one of these
diseases. One case I have heard of was entirely
cured, even after tapping" had been proposed, by
the use of the infus. pyrolae umbellatse ; and con-
tinental authors speak highly of spartium sco-
parium, and an infusion of the root of the
ononis spinosa. When it occurs early, it is pro-
bable that its progress would be best stopped by
antiphlogistic remedies and saline purgatives.
It was originally my intention to have presented
to the profession in this Appendix the transla-
lation of the whole work of M. Geromini, from
the original Italian. I have since retrenched
the chapters in refutation of the doctrines of
the late Dr. John Brown ; because the opinions
which gave rise to Geromini's arguments have
long since faded into air. Brunonianism, soon
after its appearance, exercised most extensive
influence on the practice of physic in Southern
Europe, and it is remarkable that this specula-
tive theory, which neither attained great or ex-
tended reputation in the country which gave it
birth, should have been looked upon with the
greatest respect in Italy.
Rasori, Tommasini, and the followers of the
contra-stimulant doctrines, have long since given
it its death-blow : hence no reason exists for pre-
senting a laboured refutation of its errors.
It must not be supposed that in presenting
the labours and reasoning of M. Geromini to the
profession, in an English translation, I coincide
with him in his opinion of inflammation being
uniformly the cause of dropsy : just in the prin-
cipal arguments, I think he fails in establishing
his conclusion. Inflammation, indeed, may have
caused the visceral diseases, but it is the altera-
tion of structure consequent on such diseases,
which, in a large proportion of cases, produces
the dropsical effusion.
E. J. S.
THE CAUSES AND CURE
From the Original Italian of Dr. F. C. GEROMTNT.
Of the Theories of Physicians to the time of Brown,
respecting the Causes which produce Dropsies ;
and also those of the great Anatomists who have
illustrated (the Structure and Functions of) the
The theories respecting the causes of dropsy, esta-
blished in the different medical schools, according to
the respective pathological principles which chiefly
governed them, reduce themselves, in point of fact, to
very few varieties, including those of the time imme-
diately preceding our own, in which these theories of
the ancients, with more or less dexterity, have been
Looking back to the time of Erasistratus, we learn
from Galen and from Celsus, that this physician
referred the cause of dropsy to a diseased change in
the liver, and hence rejected the operation of tapping,
as unnecessary. Hippocrates held, that dropsy was
generated when the liver was impregnated with pitui-
tous humour : and notwithstanding that, in the first
book de Morbis Mulierum, he described a dropsy
from affection of the spleen, he states clearly, that
(C hydrops ab hepate oritur quum ad hepar pituita ac-
cesserit, eamque hepar exceperit et humectum red-
From thence Galen, and the immense crowd of his
followers, established, that the cold temperament of
the liver, generating, instead of good blood, both pitui-
tous humour and water, was the cause of every dropsy.
Areteeus, the Cappadocian, who left so accurate a
description of the dropsy, appears to make it consist
in a higher degree of cachexia, in which the degene-
rated fluids change into water.
But the cold temperament did not please Alexander,
Trallianus, Avicenna, Cardanus, &c, because they
were obliged very often to treat the disease with re-
frigerating remedies : hence they decided that dropsy
proceeded from the opposite temperament.
Trincavellus, all-faithful as he was to the doctrines
of Galen, confesses that sometimes the dropsy suc-
ceeds, " ex jecinoris inflammatione, et ex inflamma-
tionibus aliorum viscerum, praesertim mesenterii gra-
cilium intestinorum.' ,
At length other practitioners perceived that this was
not always associated with diseases of the liver, but
other alterations of almost any viscus accompanied it.
Piso, Sennertus, Riverius, decided that the cold tem-
perament of the liver might well be the cause of
anasarca, in which a general poverty of healthy blood
was discerned, but not of ascites ; and leaning on the
authorities of Hippocrates and Aristotle, in reference
to the use of the abdominal viscera, attributed it most
frequently to a defect in the power of collecting the
superfluous humidity, which arose, moreover, <c aut
extinguendo, aut suflfocando, aut dissipando calidum
innatum," not alone from the liver, but also from the
spleen and kidneys : the first, Piso, having excel-
lently observed, that " tumorem aliquem alterntrius
visceris fere unam esse certe frequentissimam ascitis
parentem." Here, however, serious questions arose
how to determine by what means those fluids found
their way into the abdominal cavity ; some asserting
that they dropped by cc meatus insensibiles" (inorganic
pores of our physiologists), and others by the extre-
mities of the vessels of the mesentery, and more especi-
ally of the diseased or corrupted omentum, depending
for proof on the anatomical and pathological observa-
tions of Columbus, Heintz, Rondelezius, and others.
Finally, setting aside the chemical and spiritual
ideas of Paracelsus and Vanhelmont, and arriving at
the opinions of physicians after that " Hepar dejec-
tum fuit ab imperio sanguificationis ipsiusque publicae
ductae exequifle," we will speak of Willis, who, after the
knowledge of the existence of lacteal and lymphatic
vessels, established in reference to the causes of dropsy
a very admirable complexity of opinions, which have
been repeated even to our own days. Of the cause of
ascites, in fact, he promulgated the opinion that it was
produced either by the effusion of the serum of the
blood, or of the chyle, but especially of the former;
and of this effusion of serum of the blood he af-
firmed, that it migh t arise either from alteration of
the composition of the blood itself, or of the vessels,
or of both of these ; of which when " partes consti-
tutivas intra compagem suam baud rite continet, quia
ad dissolvendum aptus, serositates suas a mixtione
passim rejecit, quas vel foras per urinas, aut sudore
ablegat, vel intus residere permittens, in carnium
poros aut in viscerum cavitates detrudit ; ovvero juxta
arteriarum et venarum intercapedines aut inoscula-
tiones effluere sinitur."
Of the sanguiferous vessels, when their extreme
mouths or openings (( aut nimis laxa, aut processus
occlusa existunt," principally when there are schir-
rous tumours, tubercles, and other preternatural
concretions in the mesentery, spleen, liver, uterus, or
any other viscus, which delay or impede the free
course of the blood : reflecting, moreover, that the
effused fluid not " mere serosus est, sed insuper
liquor nutritivus solidisque partibus alendis desti-
natus; quare dum hsec regio intumescit, membra ex-
tenuantur et lympha ascitse exempta instar ovi albu-
minis a calore inspissatur et albescit."
Finally, to prove that ascites may be produced by
rupture, or other diseases of the lacteals and lympha-
tics, he reports the case of a patient labouring under
ascites and jaundice from whose abdomen was ex-
tracted, by tapping, a great quantity of water, not
tinged yellow, but limpid, and thence he infers w humo-
rem istum hydropicum, non e massa sanguinem pro-
fluxisse ; turn enim coloratus fuerit, sed e vasis lymphoi-
ds aut lacteis in abdominis cavitatem extillasse."
From which case, moreover, while we, for other
reasons, as well as for this, (viz., the thin and limpid
nature of the liquid,) cannot so easily accord with his
opinion that the dropsy arose from the rupture of the
lacteals, we may incidentally remark, that this ex-
ample serves wonderfully well to prove the opinions
which we are about to explain. For by admitting,
as will be seen, a new morbid process of secretion
from the inflamed surfaces of membranes as the ge-
neral cause of dropsy, it is easy to explain how the
fluid of the ascites in the case of jaundice, did not par-
take, in the slightest degree, of the colouring matter
of the bile. But it is in reasoning on the anasarca,
that Willis, repeating with his predecessors that it
arises from defect or degeneration in the blood, loses
himself in his chemical ideas of sulphur, spirit, and
salt, wishing to shew that it is a defect in fermenta-
tion and combustion (accensione), that the hydropic
diathesis consists. Etmuller leaned on Willis's opi-
nion in his explanation of dropsy ; for besides ad-
mitting the rupture of the lacteal and lymphatic
vessels, either from external lesion, or from the acri-
mony of the lymph distending and corroding them, or
from the ulceration and induration of the mesenteric
glands, he recognized that dropsy proceeded " ex-
insigni et notabile vitio in haematosi contingente
through which the blood " attenuatus et resolutus,
tandem certis in locis decumbit et extra vasa cum
vehiculo seroso subsistens tumorem talem infer t.'*
Nor does he omit, however, the other cause, viz.,
the impeded or retarded course of the blood in the
sanguiferous vessels, supported by the famous expe-
riment of Lower. Nor are the opinions of Lister
very different, who states in these words the origins
of dropsy : —
" Chylus a vitiato ventriculo ejusque digestione
cruda et imperfecta lentescit unde a venis lacteis
parum et nihil purgatus, cordis sanguinisque adeo
mo turn impedit, inque venis primum lymphae ducti-
bus, ubi motus cruoris circumacti languere incipit,
segnescit, accumulator, corrumpitur."
But Morton considered decidedly, that dropsy could
arise from rupture of the chyliferous and lymphatic
vessels, caused by the swelling of the glands of the
abdomen, of the thorax, of the limbs, " per quas ilia
vasa perrepunt et sufFulciuntur j" and that from this
effusion of chyle or of lymph, the blood " solita in-
stauratione privatus valde depauperatur accessit et
incallescit." Hence the fever, the thirst, the wasting
of parts. The history, however, which he reports,
in order to prove his opinions, demonstrates a very
different state of things. It respects a child who fell
ill of pneumonia, in whose case bleeding was
omitted, until the author was sent for very late in the
disease, as he assures us that the condition of the
patient did not improve after bleeding and blistering,
but towards the conclusion hectic fever and ascites
arose, which increasing daily, the patient died, greatly
The lungs (says the author) were healthy, except at
the posterior part, where were found " tubercula seu
glandulas pulmonales valde tumefactas," which, by
compressing (as he thinks) the thoracic duct, and im-
peding the progress of the chyle, occasioned the rup-
ture of the lacteals, and hence the continued chylous
effusion which constituted the dropsy. Every one
sees in this case, that this rupture of the lacteals, how-
ever much the illustrious author treats it as certain,
is purely hypothetical : nor do we believe that any
one, whatever may be his faith in, and veneration for,
Morton, will believe it, as Vanswieten did, solely on
his word, without even knowing if he had employed
the usual anatomical contrivances to prove the truth
of it; the more so, as it is known from Monro and
others, how very difficult, if not impossible, rupture
of the lymphatics would be. We believe also, that
no one would maintain, on such slight foundation,
that these tubercles on the posterior surface of the
lungs could in fact compress the great duct of the
chyle, so as to obstruct it in its whole course. On the
contrary, who does not clearly see, in this pulmonary
disease, a manifest indication of preceding inflam-
mation, and from this the cause of the dropsy ?
Sydenham hastens over the subject admirably, and
urges that " causa hujusce morbi in genere, sanguinis
debilitas est, unde alimento quod forinsecus impor-
tatur in substantiam suam convertendo non jam par,
idem in extremitates et pendulas corporis partes ex-
plodere necesse habet et in abdomen etiam."
Again, in considering the opinion of the great Hoff-
man, (that physician of exalted talent, formed in the
accurate school of Leibnitz, whose works we deeply
deplore should be neglected by the greater part of
young physicians, since in the midst of no few errors
incident to his time, they would find great lights of
truth, and many of the seeds of the opinions of Cullen,
and of the recent theory of excitability,) we may ob-
serve, that the same experiment of Lower, which
suggested to Willis, Etmuller, and Lister, the idea of
the retardation and stagnation of the blood in the
sanguiferous vessels, as one of the causes of dropsy
enumerated by them, moreover led the more saga-
cious and ingenious Hoffman to establish, in that
alone, the explanation of the production of the dis-
ease ; and although he has embellished this theory,
and rendered it not a little attractive in reference to
the anasarca, that the blood suffers retardation in re-
turning by the veins to the heart, and because it flows
against the force of gravity, and because " venarum
tunicae non tanta vi systaltica et motrice elastica
praeditas sunt quam arteriae;" to which he adds both
their natural and morbidly increased tenuity and po-
rosity, in consequence of which the light serum might
easily transude ; which opinion he moreover extends
to explain the formation of ascites, amplifying beyond
reason the disadvantageous condition of the circu-
lation in the liver ; in regard to which, resting on the
observations of dissections, he retains the opinion of
the ancients 9 " praecipuam ascitidis sedem 5" this
theory, we maintain, although not without the appear-
ance of truth, did not accord sufficiently w T ith just
reasoning and an accurate analysis of facts : and in
truth we must confess we cannot so easily imagine how,
during the retardation of the circulation in the veins,
the more subtle portion of the blood must transude
through their coats. It is true there may be pores
common to the whole body, and also those which have
been added by physiologists, and termed inorganic :
it must, however, be clear, even if this transudation
could happen, it demands on the one part an enor-
mous force to compress internally the column of
fluid, and on the other an absolute impediment to the
smallest progress of the circulation. Now the first
(the compressing force) cannot be imagined in the
slightest degree, if the slowness or stagnation of the
blood in the vessels (the second of Hoffman's causes
of the supposed serous transudation as a cause of
dropsy) arise from a weakness of the vessels them-
selves, or general debility of the whole frame. In
reference to the second, a cause being assumed in any
part, which, either by compression, or by any other
mode, impedes altogether the circulation of the blood
in any vessel, (which in truth it would be extremely
difficult to verify), who does not perceive that it
would be far more likely to happen that the valves
should give way, and the blood take on a retrograde
movement, than that its component parts should di-
vide, and the more liquid parts transude through the
coats of the vessels, however tender they might be ?
But here the experiments of Lower are opposed to
us ; and on this head we are obliged, for other
reasons, to stop a little, seeing that on these ex-
periments Millman rests his opinions, in his cele-
brated work on dropsy. And first of all, to take
away from these experiments a little of the appear-
ance of their irrcfragability, in the eyes of almost
all pathologists, it will not be useless to reflect, in-
asmuch as relates to the aqueous collection observed
in the abdomen of the dog, in which Lower tied the
vena cava, that the lesion of surrounding parts, which
this operation must necessarily have occasioned, might
have produced an inflammatory action, to which the
effusion mentioned would succeed : and in reference
to the tying of the jugular vein, (second experiment
of Lower), that this does not form the same case
as that in which there was an obstacle to the circu-
lation of the blood in the other veins of the body ;
since, in the one case, it would be altogether diffi-
cult for the blood to recede, because it would
have to overcome its own gravity; but not so in the
To which observations if it be added, that per-
haps in practice the case can never occur of an
obstacle to the circulation of the blood, perfectly re-
sembling that arising from the experiment of Lower
by ligature, every one sees how much is detracted
from the importance which the greatest pathologists
have attached to these experiments in the arguments
on the causes of dropsy.
And if, moreover, it should be wished that we should
explain the formation of dropsy, according to the expe-
riment of Lower, we must recollect that, having shewn
the desired serous transudation through the coats of
the vessels to be impossible, merely from an obstacle
to the circulation of the blood, we may reasonably
assert, either that the dropsy which succeeded to these
experiments, is not explicable, or that the most pro-
bable explanation that can be given after the preceding
reflections, is, that the ligature disturbing necessarily
the natural deposition of molecules in the coats of the
vessels, had excited in them an inflammatory process
capable of generating the serous effusion which
occurred ; the more, that from the observations of
Hunter, Abernethy, Sasse, Frank, the possibility of
the inflammation of the sanguiferous vessels is placed
It is clear, then, that even allowing that an obstacle
to the regular progress of the blood in the vessels
accompanies, or, if you will, even remotely occasions,
dropsy in any part, this does not prevent inflammation
(flogosi) being proximately the pathological process
which generates this disease, as we shall go on
making more clear in the progress of this work j the
more, that we shall shew in their place that those
organic alterations are produced by inflammation,
which, through the knowledge which we have of the
laws which regulate fluids out of the living machine,
here appear to exercise their morbid influence as mere
obstacles to the free circulation of the blood.
At present we must treat a little of another illus-
trious writer, Sauvages, one of the most ingenious
partizans of the Stahlian doctrine. But inasmuch
as he recognises dropsy to be simply a genus of ca-
chexia, which we have already seen to have been
the opinion of Aretseus, we shall occupy ourselves
with his theory on another occasion, when we treat
expressly on this last morbid condition ; demonstrat-
ing how very erroneously physicians have marie a
particular disease of it, while the signs of it which
they describe are merely symptoms of various forms
produced by inflammation. Proceeding instead to
Boerhaave, and his illustrious disciple, Vanswieten,
in whose much esteemed commentaries, although we
cannot expect in fact to discover new ideas on the
theory of the disease on which we are occupied, (as
Sprengel wisely observes, they are a mere collection
of humoral, chemical, and dynamic principles), or any
thing beyond the already expressed ideas of retar-
dation of the circulation, superabundant serosity in
the blood, thickening and viscidity in the lymphatic
system, vascular and visceral obstruction; we shall
begin to find joined to these, the increase in the na-
tural transudation of the membranous surfaces, or
their defective absorption, supported by the much-
praised work of the celebrated Kaaw, nephew of the
great Boerhaave, and in some measure acknowledged
even by Mead. Nor did the great Morgagni think
differently, since he maintained with the other physi-
cians, in reference to the causes of dropsy, " Quae-
cunque causa diutius potest sanguinis aut lymphae
cursuin morari, aut humoris quo cavese corporis ma-
dent prseter modum aut secretionem augere, aut
exitum deinde imminuere morbo huic potest ori-
ginem prasbere." Afterwards, a celebrated physician
of Leipsic, Ludwig, was the true precursor of the
Scotch reformer, Brown ; for, in the midst of the old
principles of the humoral pathology, acknowledging
the principal cause of these diseases, and particu-
larly of dropsy, to be general debility or atony of
vessels, and of all the animal machine, he established
the first curative induction of this disease to be in the
use of stimulants and corroborants.
" Vera itaque," he says, (in his Adversaria Medico
Practica) medendi ratio ad sola roborantia ducit.
Circulus nimirum universalis in systemate arterioso
primum sustinetur ut crasis sanguinis bona hujus
vigore efficiatur, et quern admodum etiam venarum
vis in suggendo roborantibus medicamentis incitatur
sic bona etiam mixtio sanguinis a venis suscipiendi
expeditam reddit resorptionem."
Also Milman, in his explanation of the formation
of dropsy, adheres especially to general debility, al-
though he reduces to three kinds the causes which
induce the malady.
"Scilicet ad fibrarum laxitatem, ad vires magnis
evacuantibus, morbisve acutis, in longum protractis,
demissas, vel ad impeditum revolubilem sanguinis
The theory of debility or atony, as the proximate
cause of dropsy, we find afterwards followed up by
the celebrated Vogel. But this physician prefers re-
straining it to the lymphatic system. " Multos enim,
(thus he expresses himself) cachecticos ab hydrope
prorsus immunes esse video vicessimque hydrope sac-
cato laborantes satis alacres omnisque cachexia? certe
per longum tempus expertes."
Further on he adds, that a Si languor saltern
illis vasis incumbered quae ad demittendos humores
serosos destinata sunt, certe non difficile est intel-
lectu quomodo hoc in casu oriri hydrops possit."
But a real, and not the less elegant, amalgamation of
all the opinions of writers hitherto enumerated, is Cul-
len's theory, in his Elements of the Practiceof Medicine.
In fact, after having published, as other pathologists
of that time did, that dropsy succeeded either from in-
creased exhalation or defective absorption, he laid it
down that this took place either by the bursting of
the vessels conducting the serous fluids, or the little
sacs which contained them ; that is, not only by rup-
ture of the lacteals or thoracic duct, but also of the
ureters, bladder, &c. : the natural exhalation also,
according to him, becomes increased.
1. From causes impeding the return of venous
blood to the heart, and thus preventing the free pas-
sage of blood from the arteries into the veins, in con-
sequence of which the fluids contained in the arteries
find more easily an exit by the exhalent vessels : and
as causes for this he enumerates the polypous con-
cretions in the right ventricle of the heart, the ossifi-
cation of the valves, the pulmonary hepatization,
obstruction of the liver, polypi, swellings formed in
the veins, compression of the veins by aneurismal tu-
mors, abscesses, schirrous or steatomatous tumors in
neighbouring parts, or pressure made by the gravid
2. From want of tone in the exhalent vessels, the
consequence of the general atony of the system,
occasioned especially by the abuse of spirituous
liquors, to which he gives the name of hydropic
And here we must remark, that facts themselves
oblige the author to add plethora as sometimes pro-
ducing dropsy, principally when it succeeds to the sup-
pression of some natural or sanguineous discharge ;
but in truth he thus embarrassed a little his preceding
theoretical opinions ; to make up for which, he adds
the superabundance of serum in the sanguiferous sys-
tem, derived either from the extraordinary quantity of
water introduced into the body by drinking, or ab-
sorbed from the atmosphere, or from the diminution
or cessation of the natural serous excretions, or from
copious haemorrhages, as well spontaneous as artificial,
not less than from a defect in assimilation and san-
The natural inhalation afterwards, must, according
to this author, be diminished or even destroyed*
from the enfeebled action of the extremities of the
lymphatics necessary to absorption. And this weak-
ness in the inhalent action of the lymphatics may
be, as he thinks, either altogether peculiar to this
system of vessels, (and thus he thinks that some
of the active remedies in the cure of dropsy effect it
by exciting specifically the absorbents), or dependent
on general atony.
And here it appears he rejects the obstruction of
the lymphatic vessels and glands, commonly reputed
as one of the causes of dropsy, assuring us that he has
seen similar cases, in which the larger part of the
mesenteric glands were much obstructed, although the
passage of the fluids was not visibly obstructed from
the lymphatic to the sanguiferous vessels, and dropsy
was not the result.
In reference to the hydatids observed by the an-
cients, and especially by Schenkius, as constituting
various forms of dropsy, he is of the opinion of those
who consider them to be animals. This union of the
hypothetical principles of the solid, humoral, dynamic,
and chemical philosophy, constituted the theory of
this disease, as well as of every other, in the works
of Stoll, Dehaen, Storch, Quarin, Borsieri, and in all
the treatises and compendia of practical medicine
of the second half of the eighteenth century : then ap-
peared the system of Brown. But as we must occupy
ourselves with this separately, we will proceed to the
opinions on the formation of dropsy conceived by
some of those meritorious anatomists who have illus-
trated the structure and functions of the lymphatic
system. Cruikshank distinguishes three species of
dropsies : the first arises from the debility of the whole
body, and consequent relaxation of the extremities of
the arteries, and atony of the absorbent vessels : the
second, from inflammation which has preceded, and
which has increased, the serous effusion : the third,
from the retardation by some obstacle of the free course
of the blood in the venous system ; and it is from this
last cause that he maintains with Plater and witlf the
ancients, that the extremities of pregnant women, as
well as those of persons who travel sitting in a carriage,
or on horseback, swell ; and that oedema succeeds the
use of splints or bandages in fractures, when applied
so as to compress the veins.
But the eminent anatomist of Germany, Soemme-
ring, maintaining that every dropsy depends always
on some disease of the absorbent system, prefers at-
tributing- the before mentioned morbid conditions to
compression of the lymphatics, rather than that of
the veins, supporting himself on the experiments of
Basilewtz, De Cagnion, and on his own. But among
these, in truth, what proves far otherwise than was
intended, is the inflammation of a furuncle on the
dorsum of the penis, which, by irritation of the
absorbent vessels, occasioned an oedema of the pre-
puce, which disappeared by degrees, when the furun-
cle had entirely vanished. Here, then, it would ap-
pear that he believed something more than mere
compression to have produced the oedema. But what
positive idea can we ever make to correspond with the
expression irritation, up to the present time so vaguely
employed by medical writers; and if the least equivocal
meaning which can be attached to it, is, as we see,
that in this state the mobility of the fibres is increased,
the inhalent action of the absorbent vessels, far from
diminishing, ought also to increase ; any thing, rather
than oedema, ought to be the consequence : instead of
this, nothing is more obvious to the mind than that
the oedema was effected and kept up by inflamma-
tion, in the same way as every other species of dropsy
is, as we are about to demonstrate. Nor ought the
inflammation, in the particular case, to have been
trifling, as the author clearly adds, the part was
dreadfully painful, and that stranguary, fever, de-
lirium, and convulsions, were present.
But what shall we say afterwards, of the explana-
nation given by the same illustrious author, which
he thinks he makes with some appearance of proba-
bility, of the reason why those addicted to spirituous
liquors become attacked at last with incurable dropsy,
stating that it arises in consequence of the spirituous
liquors by degrees condensing the lymph, until ob-
struction of the glands is produced. In truth, such a
chemico-humoral idea could scarcely be pardoned in
Willis ; and on this subject it does not appear to us
clear, how the physicians who have all spoken of the
abuse of spirituous liquors as the cause of dropsies,
have passed over the examination of intermediate ac-
tions, w r hich constantly occur between this occasional
cause and its effects, viz., slow abdominal inflamma-
tion \ and thus they have let escape, by erroneous
observation, by a less than rigorous analysis of facts, the
means the most obvious for revealing the true cause
of the formation of dropsy. In fact, also Cullen and
Brown, far from recognizing, by means of these facts,
how erroneous were their preconceived ideas of de-
bility being the proximate cause of dropsy, by ex-
plaining its formation from the abuse of spirituous
liquors, which are essentially stimulant, established
a principle the absurdity of which we have demon-
strated—the one calling it atony, and in the language
of Brown, indirect asthenia : but in reference to this
last we are to speak in another place.
The great Mascagni, to whom belongs, as is well re-
marked, by the clear and luminous Tommasini, " the
discovery of the lymphatics, born in Italy by the
labours of Asellius, fostered afterwards beneath fo-
reign skies, and since returned to the land which
gave it birth, there to receive perfection/' divides
dropsies into two classes : the first is the effect of the
obstruction of the glands ; the second, of the dilata-
tion of the lymphatic vessels, in consequence of which
the valves no longer impede the return of the ab-
sorbed lymph. But, in truth, these causes are not
supported by any proof; for, in reference to the first
cause, besides the fact that we do not often meet with
the glands of dropsical patients obstructed, as Cullen,
Monro, and Soemmering, assure us, it is certain that
when they are found changed or degenerated the dis-
ease is accompanied in the same dropsy with visceral
obstructions, which attest unanswerably the presence
of a preceding inflammatory process ; and we are
obliged to recognize in that very process both the
origin of the dropsy and of the glandular disease just
To the second cause may be opposed the abortive
efforts to inject the lymphatics from the trunks to
the branches ; although it is maintained by ana-
tomists that dropsical subjects presenting the lym-
phatics much enlarged, and much more visible, are
better adapted for the investigation of this system of
Finally, Walter, who, together with other illus-
trious anatomists, denied to the lymphatics the office
of absorbing the fluids from the different cavities of
the body respectively — attributing this function rather
to the veins, whose extremities he believed to be free,
and absorbing over all the surfaces — imagined that the
cause of dropsy existed solely in increased arterial
Of the sensible and well-known Morbid Processes, which
produce an effect similar to Dropsy.
From among the morbid processes which we see
under our immediate observation produce a patholo-
gical condition similar to dropsy, we will choose the
serous collection that manifests itself under the epi-
dermis, like a bladder, whenever a plaster of can-
tharides, or euphorbium, or ranunculus, or any other
epispastic, has been applied during a sufficient length
of time \ or that a part has been repeatedly struck,
or scalded with some boiling fluid. We know not
where to find facts which more clearly, or under
our own eyes, disclose the real nature of dropsy.
But it is moreover true, that the most obvious sources
of knowledge are precisely those most neglected by
mankind, as unworthy of their sublime and tran-
scendant investigations. In fact, in these very cases,
in which the blind may convince themselves of the
inflammation which always precedes and produces
this cutaneous dropsy, no one has ever run away with
the idea that the dropsy succeeds to the impeded trans-
udation of the perspiration : no one has hitherto gone
the length of saying, that the effect of blisters of can-
tharides applied to the skin (irritants similar to burns)
arises from their action moderately contrastimulating.
And does it not appear impossible that, in this case,
it should not be thought absurd, that inflammation
should be the effect of a contra-stimulus ? and that
this serous collection of which we are treating, is
really the result of inflammation, we can demonstrate
even by the examination alone of the first and suc-
cessive effects which succeed to the application of
condensed caloric, or of any other of the before men-
tioned irritating causes. If, in fact, the caloric ap-
plied to the skin is slight, nothing succeeds except
increased action in the circulation ; the part becomes
red, is painful, and sometimes it swells ; in a word,
the first symptoms of inflammation manifest them-
selves, or some of its most sensible conditions, which,
moreover, disappear either simply by removing the
external cause, or by using one or other of the means
which weaken the organic forces, and particularly by
those which subtract caloric from the animal system.
If, however, the heat applied is great and long con-
tinued, there is inevitably produced a degree of in-
flammation which causes the effusion of fluid con-
tained in the vesicles of burns ; if it be very great, it
destroys immediately, produces mortification by a
peculiar and perhaps chemical action, and in another
degree causes suppuration, and hence the reproduc-
tion of the destroyed substance : from which circum-
stances it is easy to collect, that the serous effusion is
undoubtedly produced by inflammation, and that it is
only necessary to have a given degree of inflammation
to cause one or other of its products.
At present, having established this truth, any one
has a good right to the deduction, if "iisriem effectibus
eaedem assignandse sunt causae," that also dropsy must
owe to inflammation the primitive pathological cause
which generates it ; but if any one should think the
induction not sufficiently rigorous, inasmuch as the
resemblance is not sufficiently proved between the
fluid of dropsy and that produced under the skin by
the application of blisters, or of caloric in a greater
or less degree of condensation, he may, in fact, dissi-
pate his doubts, by the knowledge that the resem-
blance between the two fluids is not limited only to
their sensible characters, but is supported by the
similar conditions of their component principles, since
both one and the other contain gelatine and albumen :
when made to evaporate, they leave an album ino-
gelatinous substance, more or less white, and which
coagulates when treated with acids.
But besides the artificial morbid process, a natural
one may be mentioned, which also generates a pro-
duct evidently similar to that which constitutes a
dropsy. In the herpes zoster, a malady which con-
sists simply of cutaneous inflammation, is there not a
serous effusion produced — a dropsy similar to that
caused by burns, or the application of blisters ?
Of the Diseases which frequently precede and generate
All the various forms of erysipelatous inflammation
with which we were occupied in the first part of this
work, may give rise to dropsy ; and here we speak as
well of those which attack the skin, as of those
which affect the internal membranes, which constitute
certain parts, and involve and confine others.
Relatively to the cutaneous diseases, we have
already seen how many impetigines, indicated under
so many names by nosologists, are no other than so
many various forms of inflammation, for the most
part erysipelatous ; proved by the pathological laws
which they follow, and which are distinctly marked,
and shewn in a positive manner, and not at all
hypothetically, by their manifesting themselves alter-
nately over the external surface and in the interior of
the human body : hence, where is the marvel that,
when improperly treated, they should give rise to
dropsy of the integuments, of the tunica vaginalis, of
the abdomen, the thorax, or the encephalon ?
But proceeding to the exanthematous diseases, the
most common among the cutaneous inflammations
from which dropsy is generated, as is attested by the
celebrated Pietro Frank, we will speak of scarlatina,
of which it is so common a result. Now, as we have
demonstrated unanswerably, when treating of the
different forms of erysipelatous inflammation, this
disease is a decided inflammation of the surface,
and even approaching a real diffused erysipelas, and
hence succeeds to similar causes, follows the same
laws, produces the same results, and is cured by the
same remedies : when enumerating the morbid pro-
ducts also, we have recognised the serous effusion
which constitutes dropsy to be the principal one.
And in truth, in order to demontrate this fact, too
often repeated, it is not necessary here to have recourse
to authorities, as cases occur daily to every practical
physician, as is asserted by the before-mentioned
master of his art, that " Copiosos nos non cellulari
modo hydrope, sed et ascite ac hydrothorace affectos,
post scarlatina tractavimus."
And in reference to these two last species of dropsy
which follow scarlatina, we must believe that the
production of them is clearly to be understood, since
we have demonstrated, by daily experience, and with
the support of the best-established observations of the
best authors in practical medicine aud pathological
anatomy, that it is peculiar to this form of inflamma-
tion, and those similar to it, to attack not only the
integuments, but at other times the internal mem-
branes which compose or involve some of the viscera,
as is demonstrated by the alterations observed in post-
Neither do we fear any opposition from the fol-
lowers of Brown, or the first reformers of his doctrine,
arising from the supposed asthenic diathesis, which
scarlatina itself will sometimes assume in common
with the other exanthemata : since we have demon-
strated evidently, 1st. That this disease is phlogosis;
2dly. That phlogosis, meaning always increased or-
ganic action, is opposed to asthenia, (and even, if we
must apply one of the Brownian visions, diathesis) it
might be said in a certain sense that it is the intense
condition of the sthenic diathesis, hence always the
same, as is the opinion of Professor Tommasini ; and
this we may assert with more confidence, since we
have availed ourselves of the same materials on which
the Brownian pathologists rest their force, and the
very authorities on which they depend.
Moreover, in reference to the scarlatina maligna, or
angina gangrenosa, from an accurate analysis of the
observations of Huxham and Fothergill, and which
we have applied also to those of Ballonius, when
treating of pneumonia, called malignant, we have
placed beyond any doubt, that very far from being ac-
companied or produced by an asthenic state of system,
it is there where we recognise the highest state of
inflammation, which rapidly changes and disorganises
the affected part. Hence, since it is wholly useless to
maintain that, in the dropsy of scarlatina the curative
indication is to excite, it rests with the Brunonians
to say, that it succeeds to the asthenic diathesis, or
when the sthenic becomes changed into the asthenic :
absurdities of the system of the Scotcli physician, and
by errors of observation, confirmed by names other-
wise illustrious and venerable. And truly, although
by one of them it is said, that dropsy succeeds to scar-
latina, from the time when it is treated with repeated
effusions of blood, we can moreover maintain that
this is a real error of observation. And in fact are
not the common people to be pardoned, when they
believe that dropsy produced by scarlatina, where
blood has been taken, has succeeded this evacuation
of the humours? And would it not be the same to
say, that in one dead of pneumonia, in the course
of which disease bleeding was employed, that the
bleeding was the cause of death ? But much more
just would it not be to judge, that the death in this
case, and the dropsy in the first, had succeeded from
the bleeding not having been employed in time, and
in sufficient quantity, to cut short the inflammation,
which in one case has produced disorganization in
the lungs, in the other a secretion of serum ? And
why is this unfortunate result of the scarlatina in fact
less frequent in these days than it was formerly,
unless, that among the more obstinate physicians,
and those attached to prejudices, which the tyranny
of the humoral pathology exercised over the vulgar,
those who are conscientious are getting rid of them,
and at present use in the cure of the same disease a
more active antiphlogistic regimen. And if any one
should be disposed to raise no small difficulty to our
manner of considering the production of dropsy after
scarlatina, by saying that it often arises in those who
are already recovered, we would excite our adversa-
ries to examine a little more scrupulously the state
of their patients, from whence they may infer, that
although in those cases in which the scarlatina ap-
pears to be cured, the vascular system has not re-
turned, and that of the integuments especially, to its
natural condition ; since even the celebrated Frank
assures us that he saw it arise in those " quibus des-
quamatio a scarlatina rite peracta non erat."
We maintain, then, that if the scarlatina is always
an inflammation, the dropsy also which accompanies
this disease is undoubtedly an inflammatory process ;
since it succeeds to all the other forms of exanthe-
mata; and all that we have already said in re-
ference to the production of dropsy must be extended
to that which arises, as we are warned by Frank,
(whom we have so often praised), " ab aliis quoque
morbis exanthematicis vix superatis, ut a morbillis,
Another form of erysipelatous inflammation, which
frequently precedes, and gives origin to the dropsy, is
that of the gout and rheumatism, as we have recog-
nised when treating on this subject, supported by
daily experience, and by the authority of Hoffman, of
Musgrave, Sauvage, Boerhaave, and Vanswieten.
And here, still more, shall we support the confutation
of the humoral pathology, on which we were occu-
pied in the same place, examining the form of inflam-
mation which accompanies gout, on which the hu-
moralists had truly much to rest, not disturbed by any
of the most zealous propagators of the theory of ex-
citability; especially if we take into consideration the
phenomenon of its alternate production in one part
of the body and in another.
But having collected together very many other
facts similar to these, which relate to other forms of
disease — seeing all these appertain to simple inflam-
mation, (however various might be the appearance,
and the occasional external causes), and more espe-
cially to that kind of inflammation termed erysipela-
tous — we were enabled to deduce the expression of all
these facts, in the event of single cases served to ex-
, plain them, without rendering it permissible to have
recourse to any hypothesis of humoral or spiritual
transference : explanations which, up to this time,
pathologists could not fail to resort to. On this very
law, then, established by means of facts appertaining
to well-known forms of inflammation similar to those
of gout, (the disease the nature of which we wished to
establish), together with the analogy of their symp-
toms, causes, and cure, we were enabled to rest the
inflammatory nature of the disease 5 declaring in con-
sequence, that gout was nothing more than a mere
membranous inflammation, and hence of the nature of
erysipelas. It remained, then, to give the last blow to
the hypothesis of an unknown humour as its effective
cause, and establish our own view in the clearest man-
ner — to make an accurate examination of the patholo-
gical results : and among these the serous effusion
which constitutes dropsy, and which succeeds in the
different parts to gout, is the principal and most frequent.
Now, as we have proved, placing beyond a doubt,
by means of the examination of many other forms of
disease certainly inflammatory, and which generate
dropsy, that this serous collection is produced by in-
flammation : thus also by the same means, while adding
an argument to the theory of the inflammatory nature of
gout, we derive another, from the morbid collection of
fluid produced by this as well as by the other forms
of inflammation, in favour of the uniformly inflam-
matory nature of dropsy, and thus observing nothing
else in this consequence of the gout but a simple
dropsy, or one of the various processes of inflamma-
tion, we may et extremas ducere exequias" of that
unknown arthritic humour, the existence of which
has been maintained with so much boldness by the
Finally, we may add, that gout attacking not only
the membranous portions of the articulations, where
it often produces hydrarthus, but, at other times, the
internal membranes, and the viscera of the human
body, we have thus another argument to prove that
the gout is a simple inflammation, and the succeding
dropsy nothing more than one of the common pro-
ducts of inflammation, especially membranous, from
the examination of the other alterations, which, with
the same serous elfusion, is observed whenever that
form of inflammation attacks the internal membranes
— the peritoneum, the intestines, the pleura — the
membranes of the brain, which (in persons dead from
gouty metastasis to the interior) are found thickened
or covered with puriform fluid, or with a layer of
coagulable lymph, and beneath it are seen either red
or livid appearances, which are at present believed
by all the best physicians to be undeniable traces of
the inflammatory process which has preceded.
Proceeding to consider the other forms of disease
which attack the viscera, and which are acknowledged
by physicians to arise from real inflammation, we shall
find in all the writers on medicine, from Hippocrates
to our own times, that among the different products
of this morbid process they have observed the accu-
mulation of fluid which constitutes the various kinds
But as even these very forms of inflammation, al-
though the clearest and most constantly distinct, have
their development and their progress obscure and
masked — as, among others, was observed by Stoll,
and is proved by Wrenhold and by Shroeder, in their
excellent dissertations on this subject — so it is not to
be wondered at that they often escaped observation,
as any one may assure himself, examining critically,
and with a scrupulous analysis, the cases relating to
the subject transmitted to us by practical physicians
and by observers of pathological anatomy, in their
condemned volumes, and afterwards comparing, at
one and the same time, their obvious product, dropsy ;
the cause of which they had sought for by a totally
And truly, only two extreme points for considera-
tion falling under their observation, in the midst of
which they saw dropsy — the first regarding some re-
mote causes, which, moreover, are either accessory
and independent, or occasioning the hidden in-
flammatory process in this or that viscus, as will be
seen when we treat of the causes which physicians
have assigned as producing this malady; the other
point regarding the alteration in the viscera, observed
in the dissection of those who have died of dropsy :
the opinion certainly was obvious that they found in
the one and the other the causes generating dropsy ;
the more so, that in the second they did not perceive
any thing except chemical or humoral degenerations,
or error loci, irregularity, or sluggishness of the circu-
lation, instead of merely inflammatory processes, as
will be demonstrated in the next chapter, in wiiich we
shall be occupied with the organic alterations which
all physicians have observed to accompany the dropsy.
But the most accurate reasoners ought naturally not to
be completely satisfied w T ith these, the doubt always
remaining whether these organic alterations which
occur, were not an effect rather than a cause of
dropsy, and the more so, as, often with dropsy, the
usual visceral degenerations are not found, and vice
versa. Hence we see some reject, as a cause, the
disease of the liver, which being in reality the most
frequently met with in dropsy, was the most fre-
quently maintained to be the cause of the disease.
Moreover, it is for these reasons (these two points
falling under their observation) that some lights of
truth are found in all the books, in the midst of many
errors on the cause ; since even Hippocrates says
clearly, u aegritudines acutas solet sequi aqua inter-
cus" ; besides very precious observations, of which we
may say that nature has done every thing towards re-
vealing the real cause of dropsy; and whilst physicians
found in all the books of practical medicine, and of
pathological anatomy, that to enteritis, peritonitis, he-
patitis, splenitis, succeeded either anasarca or ascites ;
to pleuritis, hydrothorax ; to encephalitis, hydroce-
phalus ; they could not recognize inflammation as the
cause, when this or that dropsy was presented to their
sight, unless they had been able to distinguish the
preceding inflammatory process, because it was not
manifested with the usual decided and marked symp-
But the physicians the nearest our own times, the
Brunonians, who on this subject ought to be better in-
structed than the ancients — thanks to the labours of the
deserving writers of the second half of the eighteenth
century — although they saw more clearly the visceral
inflammation which preceded dropsy, yet they still
believed in the absurd idea of" indirect asthenia," of
the change (of which they admitted all inflammations
to be susceptible,) from the sthenic to the asthenic
diathesis, in order to find a support for their beloved
theory in asthenia, as the proximate cause of all
dropsies, until the great master of his art, Pietro
Frank, following the footsteps of Stoll, cured, as we
shall presently see, several forms of dropsy with
bloodletting, and with neutral salts, which the first
Brunonians strenuously avoided, from which he esta-
blished that sometimes one of the Brunonian diatheses,
and sometimes another, may be the proximate cause
of this disease, not less than of all other morbid ap-
Examination of the nature of the Fluid of Dropsy, and
also of that which is naturally exhaled into the dif-
ferent cavities ; aftemvards of the Organic Alterations
discovered in Dropsies.
Valsalva made various observations in reference to
the nature of the fluid of dropsies, in order to see
if the difference which existed in it could afford
any means of determining its origin ; and already
many believed, with Bonetus, that the limpid fluid,
either colourless or of a very light tint, proceeded
from the vessels carrying the lymph, instead of the
veins, from which was derived the serous fluid, mixed
with other humours, and of the colour of urine.
But although some difference in the various sen-
sible qualities of the fluid of the various hydropic
patients, is actually admitted by Hoffman, Gmelin,
Senac, De Haen, Vanswieten, and by Du Verney, in
bis observations on the subject, published in the Trans-
actions of tbe Academy of Paris, there is nothing
conclusive against our views; for besides the reflec-
tions of Morgagni, arising from the change which the
fluid taken from the bodies of persons who have died
of dropsy may undergo in consequence of the longer
or shorter delay, or from other circumstances attend-
ing the post-mortem examinations, it is absolutely
necessary to observe, that this variety in the fluid,
whether it be drawn from living cases, or after death,
reduces itself to the colour, being either dark or clear,
or of greater or less density, and to a greater or less
quantity of aqueous or albuminous matter, and of
some salinejprinciple present in it.
But it may be maintained as certain, that in general
all these varieties contain albumen, since besides it
having been observed by the ancients that the fluid
taken from hydropic patients when evaporated leaves
a gelatino- albuminous substance, more or less white,
as is asserted by Sennertus, Boyle, Willis, Etmuller,
Simson, it is well known , as we have before remarked,
that treated with acids, coagula are always formed
Now that the presence of a gelatino-albuminous
substance in the fluid of hydropic patients, demon-
strated by the coagulability of that fluid, furnishes a
most important argument in favour of its being a new
product, and hence an equally strong objection against
those who regard this disease as a mere increase of
the natural fluids, is proved by the knowledge that
this coagulability is not found in the other humours
exhaled naturally in the same parts of the animal
machine where dropsy is generated : on this sub-
ject, in fact, passing over the authority of Sap-
cone, who says clearly, — " The aqueous vapour
which exhales from the organ and exhalent arteries
does not shew (when collected from a healthy body)
any signs of coagulability whether exposed to heat or
examined in the natural cavities it is certain that
Cotunnius has maintained victoriously against Lower,
Lancisi, Kaaw, and Boerhaave, that the humour
which exhales naturally from the pleura, the pericar-
dium, the membranes of the brain, and the tunica
vaginalis testis, is assuredly not coagulable in its
nature, which is particularly proved by his observa-
tions on living dogs : — " Ex vivis canibus (he says)
in hunc finem dissectis pericardii vaporem quoties de-
traxi atque ad ignem exposui, toties prorsus in auras
sine ulla, vel levi crustae specie residua, visus est
evanuisse the same is said of that fluid, " ex viven-
tium canum abdomine, desumptus, qui et limpidus et
recens, et fere inodorus ut labem nullam videretur
contraxisse, igni expositus, sine ullo discrimine totus
evanuit; quae sors testium etiam vaginae vapori
And, in fact, it is on this point that the truth
must be sought for in living animals, since in human
subjects it is difficult to exclude the suspicion that the
fluid may have arisen from disease as often as not :
hence it is not to be wondered at that Lower, Lancisi,
and Kaaw, found it to be coagulable ; and so it is, as
Cotunnius observes, each time that it is found,
<c praeter naturam adauctus." Hence " patientibus
hydrocephalon, solet cerebri aut spinse vapor coagulo
imbui : in pectoris hydrope collectae aquae coagulum
excipiunt ; nec minus illae quae sive pericardii, sive ab-
dominis, aut vaginae testium, hydropem constituunt."
And here it is observable that this illustrious
writer does not recognise the acquired coagulability
of these fluids to depend on an increase of the natural
exhalations, but gives of it an explanation, which,
although a little too mechanical, supports wonderfully
our theory of the inflammatory origin of dropsy. — cc Si
enim, (he says,) ampliora excernentia essent vasa ac
natura solent, copiosius aquam, unaque crassius serum
et coaguli capax facile trajicerent uti reapse trajiciunt
cum auctis vita viribus prseter modum distenduntur."
We may reflect in passing, that this explanation,
which is moreover the one which in this medical
school is given of inflammation, although very inge-
nious, nor assuredly improbable, yet as it establishes
a vascular condition which cannot be sensibly demon-
strated to exist, and against which some facts may
militate, so it will be sufficient for us to retain that
portion of it which shews that this morbid collection
of coagulable fluid is generated by a new secreting
process from the inflamed membranous surface of the
part in which it arises.
To this point truth assists us : if we would go further
to explain the mode in which it forms, and in what
consists the inflammation which generates it, we
should relate only hypotheses, and repeat in a more
or less neat manner the very same which have been
already related, since physicians began to write about
medicine ; and, before quitting this subject, the
qualities of the fluid, morbidly collected, which con-
stitutes dropsy, (the most important of which,
and which distinguishes it from the humours in a
healthy state, and naturally exhaling from the same
parts, is the presence of certain substances which may
he made to concrete,) we shall take leave to make a
reflection, which, besides demonstrating still more
its inflammatory origin, may serve to give a con-
venient explanation of the before-mentioned variety
in the sensible qualities of the water of different
dropsical patients ; and this is, that since, in all the
products of inflammation there is seen in greater or
less quantity the albuminous matter which may be
concreted, thus (besides having a strong argnment to
maintain that the presence of that animal principle in
parts where it did not naturally exist, indicates a pre-
ceding inflammatory process) it appears to us to be
most probable, and we shall goon still further demon-
strating it in our progress, that in these the difference
of the quantity depends on a different degree of in-
flammation, and the different form which those pro-
ducts assume of aqueous lymph, pultaceous lymph,
mucus, false membranes, polypous, and osseous con-
cretions, are owing, besides the various degree and
cause of the inflammation, to the difference in the
occasional causes and the nature of the affected parts.
And in truth also there appears visibly to exist a
certain gradation in the composition of these effects
of inflammation which demonstrates an equal relative
gradation in the severity of the inflammation which
produces them, since even on the surface of the
body fluid is seen to collect after a slight inflammation
and from slight injuries ; the process, on the contrary,
being severe, when induced by severe or violent
causes. For which reasons, besides the means of very
reasonably maintaining that dropsy is one of the pro-
ducts of inflammation, we may also establish these
other facts : —
1. The dropsical fluid, which contains less than in
other cases of dropsy the principle of coagulable al-
bumen, is one of the most simple forms, and hence
the result of a slighter inflammation.
2. That the variable quantity of the same animal
principle occasioning the obvious varieties in the sen-
sible qualities of dropsical fluid, depends, as we have
already remarked, on the variable degree of inflam-
mation which has produced it : and is it not shewn
by the fact that the denser and deeper coloured fluids
containing a greater quantity of coagulable principle,
and thus acknowledging a more severe inflammatory
process as a cause, has induced physicians to declare
that such a condition affords an unfavourable prognosis ?
But the morbid inflammatory process which pro-
duces dropsy in different parts of the animal machine,
is very often not limited solely to the production of
fluid which constitutes this disease, but in proportion
to its severity gives rise also to several other more
complicated forms of the products of inflammation,
which are often found at the same time with dropsy.
And already we have remarked, that from the time
of the most ancient physicians, different visceral al-
terations were found co-existent with dropsy : but by
these little was remarked, except the most obvious ex-
ternal appearances; hence described by the un-
meaning appellations of obstruction, swelling, or the
still more vague word corruption, while their real
origin was not established, as we have shewn, except
hy some of the best writers of the second half of the
past century, and above all by means of the late patho-
logical investigations of some of the illustrious zoono-
mists who at present adorn Italy.
In fact, passing over Columbus, Heintz, Rondelezius,
Bartolinus, Peyer,Trincavelli, Sennertus, Willis, Piso,
Zacutus, Riverius, Etmuller, Morton, Littre, Sassonia,
Plater, Horstius, Tulpius, Ruischius, Bonetus, and
a thousand others, who in their observations on this
disease speak to us in the already mentioned language,
in reference to the organic alterations occurring in
cases of dropsy, either in the abdomen, or the chest, or
the brain, we come to the great Hoffman, who leaves
us nothing better, saying of the liver that "plerumque
morbidum fuisse repertum, et nunc quidem pallidum
et fere exangue, nunc tumidum et atrum, tensum,
schirrosum and of the other viscera, " omentum in
dissectis ascite defunctis ut plurimum inveniri cor-
r up turn et sphacellatum vel plane extenuatum et ab-
suntum, pancreas schirrosum, et mesenterium ob-
vesicas quibus interius obsidere solet, aqua repletas,
et glandulas ad fabse magnitudinem tumefactas, in
magnum molem excretum j" and it is only of the in-
testines and of the stomach that he expresses himself
a little better, saying, " neque intestina cum ventricnlo
reliquuntur immunia ; sed ista observari inflammata,
giderata et corrosa."
We will say nothing of Sauvages, who without
ever alluding to the inflammatory cause of dropsy,
assures us, however, that in those dead of this disease
there are found " viscera plurima nunc hsec nunc ilia
obstructa, indurata vel etiam remollita, semiputrida,
callosa, rettorida, granulosa, suppurata, absumpta,
adaucta et saepissime hepar, dein lien, mesenterium,
pancreas, uterus, rarius renes, epiploum, pulmones,
But what has always been to us a subject of the
greatest wonder, is the attentive consideration of the
great work of the so much venerated Morgagni, " De
Causis et Sedibus Morborum," which includes, as in a
treasury, all the principal and most interesting patho-
logical observations registered in the preceding im-
mense works of practical medicine and of patholo-
gical anatomy. How is it possible not to be astonished
that he, who in the 38th Epistle — set apart for the ex-
amination of different dropsies, from the various
dropsical cases which occurred in the practice of Van-
salva and in his own, in each of which, both from the
history of the symptoms and from the organic altera-
tions occurring with the effusion, it is sufficiently clear
that an inflammatory process preceded them and accom-
panied the effusion — does not mention one in which
he recognises either the pathological alterations or the
dropsy, as being generated by inflammation ? And,
in truth, it is very singular how this very celebrated
anatomist, from the numerous observations which he
delivers to us, in which at one time one viscus,
at other times a different one, or one or other of the
membranes were enlarged, or hardened, or cor-
rugated, or covered with purulent matter, or adherent
to neighbouring parts, never speaks to us of the
preceding inflammation, and still less as of a pro-
cess producing the disease, and only sometimes treats
of the inflammation at all of one or other of the vis-
cera \ and, among the pathological observations which
are mentioned, the collection of fluid is one in which
he still more rarely recognises the preceding inflam-
mation of the parts in which it occurs.
Thus it is not until the 20th Epistle, in which, (after
having erroneously maintained that in the three cases
of pneumonia registered under the Nos. 30, 32, 33, in
which fluid was found in the chest, that it was indepen-
dent of the visceral inflammation, and even had pre-
ceded it,) he says clearly, following Coiterus, that
sometimes dropsy of the chest maybe generated at the
same time with pleurisy and pneumonia. But behold
the beautiful explanation on the cause of dropsy which
has been left us in this case by a writer on whom so
many encomiums have been heaped. " Quod si huic
inde, et sanguinis per pulmonum vascula circumitio
retardetur, et humoris ex intima asperae arteriae, exti-
maque totius corporis superficie invisibiles quidem sed
innumerse jugiter prodeuntes particulee cohibeantur ;
ha? per aliaaliarum membranarum foraminula exitum
molientur, earumque praesertim, quae magis tunc ca-
lentes, magis quoque patulos, habebunt poros, hoc est
thoracem intus, ej usque viscera convestientium."
But do not all the phenomena, visibly manifested
in inflammation, shew something different from re-
tardation of the circulation? and what afterwards shall
we say of the explanation borrowed from the physi-
cal properties of inorganic bodies, that dilatation
of the pores has reference to the high temperature of
the part !
Finally, that which most deserves to be mentioned
by us, in reference to this highly prized work, and
which places beyond dispute our theory on the for-
mation of dropsy, is, that of more than two hundred
cases enregistered in it, of aqueouscollections occurring
either in the thoracic, abdominal, or cerebral cavi-
ties, all present at the same time either thickening of
the membranes, or hardening, or tubercles, or ulce-
rations, or steatomatous concretions of the viscera, or,
above all, adhesions of some viscus or membrane to
the adjacent parts, either directly or through the me-
dium of new fibres and false membrane : all altera-
tions, the inflammatory origin of which, although even
to these days so little known, is now maintained by
the best modern physicians; thanks to the labours of
Wrenholt, of Shroeder, of Frank, and especially of the
Italians, Tommasini, Rasori, Rubini, Pisani, which
will be demonstrated in the second part of this work.
For this reason we do not think it necessary to stop
long, in confuting the idea— which, however, is found
in all medical books, and even of those nearest our
own time — that these described visceral alterations
are produced by the "stasis" of the water; on which
point, moreover, to render the fluid fit for the pur-
pose, it was necessary, from the time of the old physi-
cians, to imagine, that it was impregnated with
sulphur and salts, which, with their poignancy, ren-
dered them more acrid, pungent, and corrosive; ideas,
the plain absurdity and ridicule of which, the ever-
dominant humoral pathology did not permit to be
exposed. But at present that this system has lost
no little of its tyranny over the mind, we cannot be-
lieve that there is any physician of good sense, who
(since in practice we see individuals who have been
afflicted with dropsy during many months and years
become cured, either by appropriate treatment, or
even without any assistance from art), is not capable
of making the obvious reflection, that if the stasis of
the fluid was the occasion of the visceral alterations
met with in this disease, how would it be possible to
effect a cure and a return to good health, after so long
a delay. Hence we cannot participate in the astonish-
ment of Vanswieten, in reference to that lady, who,
after three years of an immense ascites, Mead having
extracted by puncture sixty pints of fluid, " nunquam
rediit hydrops, et elapsis decern mensibus filium ro-
bustum perperit, plurium postea prolium fsecunda
Nor in truth do we fear either the objections of any
one who might pretend that sometimes the viscera
in persons dead from dropsy are found healthy, and
instead the lymphatic vessels turgid, or the authority
on which this might be based. In the meantime
behold the principal observation of Valsalva on this
point, which Morgagni gives us as those on which he
believed he had sustained the proposition.
" Foemina viginti sex circiter annorum quae uterum
non semel tulerat, post animi perturbationes to to cor-
pore leviter, abclomine magis intumescit, difficulter
et erecta respirat, neutrum in latus laboriose de-
cumbit, ingens in thorace pondus percipit, maxime
sitit, donee difficultate spirandi ingravescente, mor-
tem obiit. In ventre pauca erat aqua, sed ventri-
culus praeturgidus etbepar magnum adeo diaphragma
sursum pellebant, ut thoracis cavea minor fieret.
Ceterum lymphae ductus turgebant in ventre, cuncta-
que hujus viscera bene se habebant, si indurata exci-
pias ovaria, thorax omnino aquae plenus. Pulmones
non nihil duri, et rubri, variisque maculis nigris dis-
tincti, caetera sani."
And is it not sufficient to get rid of the most blind
veneration for such great names, to discover that
errors of observation are not altogether foreign to
them. And, in fact, if any one can go so far as to say
that all the viscera of the belly are healthy, after
having stated that u Ventriculus perturgidus et hepar
magnum adeo diaphragma sursum pellebant, ut tho-
racis cavea minor fieret," if it be asserted, as a trifling
and inconclusive alteration of the lungs, when they
were found iC duri, rubri, variisque maculis, nigris
distincti," what can we ever relate or believe to be
true, or exact, or precise, grounded on their judgment
of the healthy or morbid condition of the parts.
If, then, after the accurate examination of the post-
mortem observations noted by the most illustrious
writers on practical medicine and pathological ana-
tomy — nor less of those which all physicians have a
daily opportunity of making in the bodies of those
who die of dropsy — we gather, that almost always or-
ganic alterations are met with, in this or that viscus,
which indisputably demonstrate that they have been
preceded by a pathological process, inflammation, may
Ave not faintly flatter ourselves that we have brought
to light a very strong argument in favour of our theory
of the inflammatory cause of dropsy ?
Of the Method of Cure pursued in all times, although
not always in accordance with the different Theories
of the Schools.
By the attentive study of the best works on medicine,
from the time of Hippocrates to our own days, it is
easy to observe, that in the midst of so many erro-
neous ideas left us on the origin of Dropsy, in propor-
tion to the different theories which, in various times,
ruled the various medical schools, the method of cure
resolved itself always into evacuation of the animal
humours ; to which were added, by some physicians,
powerful means to increase the activity of those or-
ganic functions which maintain nutrition, and the
necessary harmony of parts.
And physicians were doubtless led to the evacua-
tion of the humours, from having all observed, as Van-
swieten remarks, " naturam sa?pius banc viam indi-
care in sanando hoc morbo."
Hippocrates, in fact, had before observed: —
" Hydropicis secundum venas aqua in alvum pro-
rumpeute solutio fit (Coac. prsenot. n. 467). Hydropi
incipienti alvi profluvium aquosum superveniens citra
cruditatem morbum solvit (Coac. prsenot. n.457), spb-
aquoso etlienoso, albaque pituita detento alvvis vehe-
menter, perturbata, bonum (De Morbis, lib. i. c. 4,
et aphorism 29, sect. 7)? which orders the dropsical
patient, if naturally " non purgetur, medicamentum
dehorsum purgans, quo aqua purgetur exhibito, (De
Morbis, lib. ii. c. 28) ; and in another place, tc si alvus
sponte turbata non fuerit, cucaro dato, aut hippophae,
grano gnidio, vel magnesio lapide purgare oportet.
(De Inter. Affect, c. 22.)
And here it must be remarked, that not only does
he wish to evacuate the humours by the belly, but also
by the cutaneous transpiration, since in the last place,
whilst prescribing for the diet substances proper to
excite the circulation, and increase the proper nutri-
tion of parts, he orders, moreover, that the patient
should walk twenty or thirty stadia per day : and
the book, "De Vict. Ratione in Morbis Acutis," whe-
ther it be or be not by Hippocrates, clearly re-
cognizes also the evacuation of blood as a means of
cure in dropsy. " Quod si difficultate spirandi tenea-
tur, anni tempus aestivum fuerit, aetas vigeatet virutn
robur adsit, sanguinem ex brachio detrahere conve-
nit." Nor does he pass by the operation of para-
centesis, saying — " Si igitur medicamentis et reliqua
victus ratione juvetur et venter molietur ; sin minus,
sectione facta, aquam educere oportet, (De Affect,
sect. 1, 6.)
This method of cure by evacuation served as a rule
to the Greek physicians, both ancient and modern,
and even the best of these, Alexander Trallianus, is
seen manifestly to incline to, as well as to recognize,
the inflammatory origin of dropsy, in the use of the
evacuating treatment, saying openly, that " nullum
valde calefaciens jnvare potest, nam ejusmodi medica-
menta situm ipsorum (hydrope detentorum) augent
et febrem intendunt, et cansas inflammantes, magis
adhuc exnrunt intenduntqne malum." Hence he
had no difficulty in ordering bloodletting ; as was
also the case with Paulus iEgineta.
Celsus, in his cure of dropsy, recommends evacu-
ating remedies ; above all of which, he praises the
squill, and likewise lays much stress on exercise,
frictions, and the hot bath, especially the sand bath,
which, commended by all the physicians of the metho-
dical sect, it must be seen cannot be of utility in
many cases, except by the abundant perspiration
which follows its employment.
But this work would swell into an immense volume
if we were to report the method of cure which is
found described in the great series of the works of the
Greek, Latin, and Arabian physicians ; nor do we think
it convenient, inasmuch as any one, by the study of
the same, can easily convince himself that the most
active part of their treatment, all-complicated and
contradictory as it was in this disease, not less than
in many others, was always by evacuating the animal
humours, by means of the use of emeto-cathartic re-
medies—diuretics and diaphoretics. In the same way,
we shall say nothing of those physicians, who, at the
resurrection of science, re-established the Greek
physic, which, for this very reason, could not be difte-
rent from the former ; and, in fact, the same is found
in the cases of dropsy which we meet with here and
there in the many hundred of practical observations
collected and transmitted by the observers of the six-
Also we shall say nothing of the chemical physi-
cians, it being well known to all that their most pow-
erful medicines were violent evacuants, which could
not be otherwise, being preparations of antimony and
mercury, of whose miraculous efficacy they boasted
so much : and, in truth, although we are far from
lending our faith to the vain-glorious Van Helmont,
who says, " Se supra bis mille hydropicos, etiam
quod lotium jam ex cruento inquiaret, et tota nocte
vix uniira cochleare minxerant, in pristinum sanita-
tem restituisse nevertheless, no one can assuredly
deny that those physicians were very fortunate in their
cure of dropsy, and had effected cures, surprising and
miraculous, among other physicians : nor shall we
occupy ourselves with the modern Iatro chemists and
Hippocratists, since from their theories, which we
have before glanced at, we can easily understand how
their curative method must have been to evacuate the
animal humours. Such, in fact, was that of Willis, of
Sennertus, of Piso, of Etmuller, and Riverius, and
many others. In reference to this last, it may not be
useless to observe, that of the fifteen or twenty cases
of dropsy, related by him among his own observations,
or those of others, there was not one in which, while
it was impossible not to recognize clearly that the
collection of fluid was the sequela of synocha, of
puerperal disease, of acute or chronic inflammation, of
the spleen, liver, and lungs, &c, we do not see also
in the formulae of medicines, with which the patients
were treated, a decidedly evacuating treatment, con-
sisting of mild or drastic purgatives, diuretics, and
But in reference to Sydenham, it is very well worthy
of remark, that having maintained a defect in sangui-
fication to be the cause of dropsy, and although the
theory would lead him to a totally different practice,
the first indication of cure laid down by him is the
evacuation of the water, to effect which he makes the
most courageous use of drastics, of emetics, and of
diuretics ; and still further, after having fulfilled the
first indication, he lays it down for the second to give
corroborants, nevertheless believing it to be neces-
sary only with aged patients, or those " qui alios minus
sani corporis habitu sunt praediti while young pa-
tients u aquis rite expurgatis, sine alio quovis prsesidio
convalesca^.'' To which, if we add the reflection that
in fact in all cases of dropsy reported by him no other
treatment except by evacuation is reported, any one
may easily deduce, even from the observations of this
illustrious writer, the truth of the ideas which we are
explaining, of the origin and cure of this disease.
In pursuing the subject, we have seen that a precursor
of the theory and practice of Brown was certainly
found in Ludwig, who having established the general
debility or atony of vessels and of the whole animal ma-
chine as the primary cause of dropsy, decided that " vera
medendi ratio ad sola roborantea ducit." But here
we must observe that although this author, according
to his preconceived theoretical idea?, declares himself
opposed to purgatives in the cure of this disease, he
uses many other evacuants, sudorifics, and diuretics,
among which he praises especially the squill, in
which it appears to him, " invenire stimulum aliquem
efficacissimum and in regard to the vital action of
this medicine, it is singular to see how nature would
almost per force convince him of his error, and reveal
to him the opposite truth. " Tentavi quidem," he con-
fesses, "scillee connubium cum roborantibus et infuso
corticis peruviani concentrato aliquam scillae partem
addidi ; sed tentamina ha?c semper inania fuerimt."
But what avails, (i when caecutire volunt?"
Now see the explanation he gives of this : " Prop-
teria quod robur solidorum nunquam nisi post evacua-
tiones consuetas non nihil auctas instaurari potest,"
which is as much as to say, by way of removing de-
bility it is necessary to debilitate the patient more
The same reflections we may repeat in reference to
Milman and Vogel. The first of these, whilst in his
explanation of the origin of dropsy, he attaches him-
self, as we saw, especially to debility, that is, "ad fi bra-
rum laxitatem ad vires magnis evacuationibus, mor-
bisve auctis in longum protractis, demissas" — to which
he adds, " Impeditum revolubilem sanguinis cir-
cuitum" — nevertheless confides the cure princi-
pally to evacuants, and " quidem drastici," as the
pills of Bacher, so much praised by him. Even in
the observations of dropsies reported by him, while
they demonstrate evidently the preceding and accom-
panying inflammation, the method of cure is seen to
have been actively evacuant, since he did not omit
even venesection, in spite of slipping in some exciting
potion in the midst of these heroic purgatives. And
Vogel — who preferred restricting the idea of atony as
the cause of dropsy to the lymphatics, without giving
himself the trouble to explain how the evacuative
means which he suggests relieve the condition laid
down by his theory (which he would have found not a
little difficult), follows the physicians of all ages, " et
ipsum naturae ductum;" saying that " purgantibus
imprimis ac diureticis, scorsim et conjunctim interpo-
sitis tonicis exequenda est."
Finally, also, the most powerful defender of atony,
the graceful reformer of the theories of Hoffman, the
celebrated Cullen, after having established these three
curative indications on the theory of dropsy —
1 . To obviate the remote causes of the disease ;
2. To evacuate the accumulated serum ;
3. To excite the energy of the system ; — like all other
physicians he lays the greatest stress upon the second,
which he says he is satisfied of effecting by determin-
ing serous excretions, by means of which the absorp-
tion in the diseased parts is re-excited.
But to purge, to evacuate the humours by the sto-
mach, the intestines, the kidneys, or the skin, was the
principal curative indication of Quaun, De Haen,
Storch, Borsieri, and, above all, of Casimir Medicus,
and Stoll, by whom the antiphlogistic method
was courageously adopted, not even omitting vene-
section. When the great system of Brown ap-
peared, according to whom dropsy ought to belong to
the class of diseases of the asthenic diathesis, fanatics
began to disclaim against the common antiphlogistic
method, and employment of salts which produce
Explanation of the Cause of Dropsy, taken from the
Reconsidering for the moment the materials de-
rived from the preceding observations, it is quite
clear that we have discovered five most important
facts : —
1. That the collection of fluid constituting dropsy,
in the different parts of the animal machine, is most
similar, both by its sensible qualities, and from the
principles detected in it by chemical analysis, to that
which we see produced on the surface of the body,
whenever certain forms of inflammation, produced
either artificially or naturally, are developed there ;
and hence, that the collection of this last, whenever
produced under the epidermis, may be considered as
a true cutaneous dropsy.
2. That the fluid of dropsy is, on the contrary,
wholly different in its component principles from the
fluid which naturally exhales in the different cavities
of the animal machine.
3. That among the productions of inflammation
which attack the different parts of the body, dropsy is
the most frequent, (principally speaking of erysipela-
tous inflammation), is demonstrated by the practical
and anatomical observations of all the greatest writers
of ancient and modern times, it having been seen
always as at present that the anasarca, ascites, hydro-
thorax, and hydrocephalus, were generated by vis-
ceral inflammations ; and above all by inflammations
of the skin or membranes.
4. That in all patients who die from dropsy, from
whatever remote cause it may be supposed to have
proceeded, organic alterations are always found, ir-
refragably demonstrating a preceding inflammatory
5. That the principal method of cure, and the most
successful, pursued in all times, was always to pro-
mote the secretion and evacuation of the animal hu-
mours ; and, in some cases, at the same time to
increase the activity of the functions of organs which
maintain the necessary nutrition of parts : hence that
from the exclusive use of stimulants, properly so
called — wine, spirits bark, aromatics, no one has ever
succeeded in curing dropsy.
Now adhering to the facts of the first class, we
can establish first of all, that in order to constitute
this disease, the dropsy, it is not necessary that the
morbid collection of fluid should be formed in the ca-
vities, or quasi cavities of the human body, as all the
modern works, even the most recent, on medicine and
surgery, affirm ; that is, where naturally a certain
vapour is developed, and perhaps condensed in part
in the form of a little water, which is always being
dissipated by means of the absorbents, and regenerated
by the vascular extremities of the exhalent arteries.
In fact, when the aqueous collections are formed, as
we have seen, between the epidermis and the skin,
can any one imagine a cavity between them in their
natural state ? If, then, any part of the animal ma-
chine, hollow or not hollow,' separating or not sepa-
rating that natural humour, is susceptible of dropsy,
the idea universally put forth, that dropsy consists in
a merely exuberant collection of the humour naturally
exhaling from the membranous surfaces of the in-
ternal parts of the body, begins to be esteemed
false : an idea the erroneous nature of which is de-
monstrated to the plainest evidence by the facts ap-
pertaining to the second class. Instead of this, who
does not see, both from the first and second reasons,
that it must be admitted as incontestible, not only that
dropsy depends on a collection of fluid, which did
not exist before, or on a new morbid secretion, which
the vessels of the surfaces of the part in which it
commences, form, but also, that the morbid state
which renders them capable of producing this
dropsy is inflammation. And in truth, from these
two classes alone of facts, we might with sufficient
reason have established the truth of the theory of the
formation of dropsy ; but we wished to have other
arguments, and we have found them in the examina-
tion of the three other classes of facts which occupied
our preceding investigations : the last of which will
suffice to establish also the true theory of the cure,
and consequently the curative indication, which in-
cludes all the facts contained in the history of me-
dicine, confirmed by the practice of other physicians.
Hence in reference to the production of this dis-
ease, each will see not only demonstrated our theory
of the universally inflammatory cause of dropsy, but
that all other causes remain excluded, because con-
tradicted by one or other of these classes of facts.
And this last consequence we should altogether
abandon to the perspicuity of our readers, as we do
all the theories anterior to those of the Scotch physi-
cian, Dr. Brown, if the too notorious opinion of this
reformer, and its modifications in the present day, did
not oblige us absolutely to occupy ourselves with the
consideration of it.
On the false opinions commonly put forward, from
errors of observation on the remote causes of
Do, then, the dropsies commonly believed to succeed
to debilitating causes, depend on inflammation ?
Here let us be permitted to institute an impartial
and candid examination of those causes, called occa-
sional or predisposing, which hitherto all physicians
First behold that of Boerhaave, which it will be
quite sufficient to mention here, because it may be
seen copied in all other books of theory and practice
" Dispositio gentilitia: potus nimius frigide sum-
tus neque vomitu, neque alvo, neque sudore vel urina,
calore, motuve excitatis excretus : morbi acuti, in
primis ardentissimi, sive cum site potuque inexplebili
sive sine his : dysenteria lienosa, diu permaneus :
omnes pertinaces viscerum obstructiones, ut scirrhi
hepatis, lienis, pancreatis, mesenterii, renum, uteri,
* The Seventh Chapter is omitted, as consisting entirely of
arguments against the Brunonian theory.
intestinorum : icterus : quarlana sa?va et podagra :
evacuationes qusecunquc nimise, maxime sanguinis
arteriosi : haustus acrium, fermentatorumque liquo-
rum : victum tenacium, durorum : hydatides in-
gentes, plures in cavo abdominis pendulae, et plura
similia ut melancholia, scorbutus."
Who does not see us borne out in what we asserted
in another place, that all physicians had held, as
causes of dropsy, only those effects which accompany
it, and of causes also which neither dispose to, nor
occasion it, but can alone be the occasional and pre-
disposing causes of the first pathological process which
And respecting the hereditary disposition to this
disease, (which we might think complimentary to
Boerhaave to enumerate as a remote cause, although
indeed it received but very little support from his
accurate commentator Vanswieten, in bringing for-
ward the superstitious custom of which Plutarch
speaks, regarding the sons of persons dead of dropsy
bathing their feet in the water of the ascites,
at the burning of the corpse, under the idea of
protecting themselves against the disease), it must
be remembered that even were it established by
decisive observations, it presents no obstacle to our
doctrine : for on this subject the same observa-
tion may be made on dropsy as on phthisis, which
is, that as such an organic disposition of the viscera
may be inherited as to render the patient more
easily attacked by inflammation, so this inflammation
may be disposed to produce dropsy rather than any
other consequence of inflammation ; otherwise it is
altogether erroneous, and not conformable with ac-
curate reasoning, to say that dropsy recognises here-
ditary disposition as an occasional or remote cause.
Frank, moreover, does not much believe in this he-
reditary predisposition, but proposes instead, sex, age,
and certain employments, as occasional causes : —
saying, " Attentionem meretur in hydropem dispo-
sitio sexus fceminei, foetus in utero, setatis infantilis,
senilis, hominum litteratorum, artificium vitam seden-
And here, indeed, although it is evident that there
is no other foundation for this than as it were arises
from the inheritance of the Boerhaavian and Cullenian
philosophy, we may make an observation similar to
that on the hereditary disposition, viz. that in one or
other sex, at one or other age, there may be a dispo-
sition to receive an inflammatory action more dis-
posed to end in dropsy than any other of its termina-
tions ; since, in fact, when women and young children
are attacked by inflammation, it is for the most part
of the erysipelatous kind ; but never can it be said
rigorously, that sex and age are predisposing causes
of dropsy, as also by no means are certain occupa-
tions. And it was only to sustain some humoral, dy-
namic, or chemical theory, that it was asserted, that
stone-cutters, tailors, shoemakers, weavers, stove-
makers, fishermen, and washer-women, were more
subject to the disease than others. And although
Ramassini says of millers : — " Non paucos asthmaticos
factos, ac tandem in hydropem lapsos observavi," it is
quite clear that neither the flour nor the powder, to
which he attributes it, can give occasion to the dis-
ease, except by giving origin to inflammation of the
viscera of the chest : nor does it produce a greater
difficulty, the asserting, with Zacchia, that gardeners
are subject to dropsy, when it is impossible not to
see, in their habits and the nature of their labour, an
abundant source of causes occasioning slow inflam-
mation of the viscera of the abdomen and the chest.
In reference to infancy, it is unnecessary to notice
how much the dropsy in the foetus depends on in-
flammation ; it being well known how much it is ex-
posed to suffer from injuries or wounds inflicted on
On cold drink we agree entirely with the excellent
observation made by Frank, when he says : — " Mor-
bos alios quidem, sed minime hydropem nisi secunda-
rium ex illis oriri videmus and when it occurs it
probably depends on enteritis or some other visceral
inflammation, which practitioners have often seen
succeed to copious draughts of cold fluids, " post
We shall say nothing here of acute diseases, inflam-
matory fevers, visceral membranous inflammations,
and the exanthemata, as causes of dropsy, having had
our attention occupied with these diseases in another
place. Instead of this, it will not be altogether use-
less to consider a little the dysentery, because many
have believed that, in the progress of this disease and
in other profluvia, they have found a most serious
objection to our opinions on the cause and formation
And here we must first observe, that Frank, in his
much lauded observations on dysentery, shews that
he really understood the nature of the disease, since
he describes evidently, inflammation of the intestines.
But he would not undoubtedly have injured the result
of his labours, if he had avoided modelling them on
the abstract classification of Brown, and if he had not
mingled with inflammation a theory imaginary in
itself, and repugnant to the doctrine of inflammation —
the asthenic diathesis ; and had he not done so, he
would have undoubtedly acknowledged that when
dysentery is supposed to have passed into such a
condition, nothing has occurred otherwise than the
establishment of organic disease produced by inflam-
Let us pass over his other error in believing " eflfec-
tus dysenteria? frequens, inflammatio diversae indolis,
intestini recti, aut coli erysipelacea, interdum pro-
fundior est while in fact, instead of the morbid se-
cretion, and the mucous evacuations of the intestines,
which were called dysentery, these are in fact the
consequence of inflammation of the intestines, pro-
duced either by miasmata, or some other external
cause. Hence there is nothing wonderful in the
spreading of this inflammation even to the external
surface of the intestines, or, in very severe cases, to
the whole of the abdominal and even the thoracic
viscera, as may be collected from the observations of
Dr. Pisani, in his excellent work on the Epidemic
Dysentery which existed in the Military Hospital of
Mantua, in the years 1811 and 1812.
We shall say nothing here on visceral obstructions
as causes of dropsy, because we have already pointed
out that we shall prove in their proper place that
these are simply the effects of inflammation, in the
same manner as all other organic degenerations are.
Hence we may maintain, that when they are found
with dropsy, they are only the effect of one original
pathological process, and that they accompany dropsy,
but are not the causes of it : and the same may be
said of jaundice, which every body knows to be most
generally one of the symptoms of either acute or
And in speaking of these organic alterations, sup-
posed to be the causes of dropsy, it will be as well,
lest any should hope to oppose our doctrine in re-
ference to the diseases of the heart, from which may
be inferred the impediment to the free course of the
blood as a cause of dropsy, and hence an objection to
the universality of our doctrine of inflammation, to ac-
knowledge before hand, that we shall demonstrate all
these alterations to proceed from inflammation attack-
ing the heart and great vessels, which either renders
their structure so soft that dilatation succeeds, or, on
the contrary, thickening and hardening the parietes ;
or causes the effusion of coagulated lymph, which
produces the adhesions, the fringes, or the concretions
called polypi, so variously described by authors on pa-
thological anatomy : hence nothing will be more
obvious than that inflammation attacking also the
pleura, the mediastinum, and the pericardium, should
give origin to the dropsy which accompanies these
And it is easy here to resolve the question pro-
posed by Frank, speaking of the sudden starting, with
pain and agitation, which accompanies hydrothorax,
and which he recognises as a symptom of many dis-
eases of the heart — whether this ought to be con-
sidered as a cause, or rather an effect of dropsy, when
observed at the same time with it : we answer, that
neither is this an effect of such diseases, nor those dis-
eases resulting from it, but both the disease and the
symptom owe their origin to one and the same cause.
But in reference to the discharges of blood, which our
adversaries consider as victorious arguments against
our opinion, what would they have ? Hildanus cites
a case of a dropsical patient, in whom epistaxis oc-
curred, and who lost four pints of blood: — "Non
tantum vires redierunt, verum etiam ab hydrope citra
ullorum aliorum remediorum usum brevi curatus est
8eger.' , Besides, how happened it that the soldier,
in whom the thyroid artery was wounded, (and was
saved by my excellent friend Palizzini, by means of
large bleedings), did not become enormously drop-
sical ? and in the case of the other soldier, reported
in Brugnatelli's Journal, who, after a wound of the
carotid artery, lost twenty-five pints of blood, imagine
what happened,— a sudden and extreme wasting of
the body ; that is to say, an extreme increase in the
inhalent vigour of the absorbents, or in other words,
a condition exactly opposed to that which permits the
formation of dropsy. And are there any physicians
who have not seen patients labouring under aneurism
have their lives protracted during no short space of
time, by bleeding, repeated often during the month,
without any dropsy supervening ; and if such dropsy
should have succeeded, will they deny that, on the
post-mortem investigation, undoubted traces of in-
flammation, either of the thorax or abdomen, were
visible ? And if this be true, are we not authorized to
consider simply loss of blood, as a cause of dropsy, to
be altogether hypothetical, and even impossible. But
our opponents will say, do we not see dropsy every
day succeed acute diseases treated by large bleeding ?
Yes, certainly, and also after uterine haemorrhage, from
protracted or difficult labour, after haemoptyses, &c.
But when dropsy succeeds after bleedings in inflam-
matory fevers, or visceral inflammation, what phy-
sician is so dull or short-sighted, as not to conclude,
as we have otherwise observed, that the dropsy su-
pervened, not in consequence of the evacuation of
blood, but because it was ordered late, and was in-
sufficient to stop the inflammatory condition ?
And in the acknowledged cases of haemorrhage,
after which we allow that dropsy is developed, who
can deny that an inflammatory condition in this or
that part may be discovered by an attentive physi-
cian ? And does not this occur because inflammation
is going on in these cases of haemorrhage, to which
dropsy succeeds ; while the latter disease never oc-
curs after vast losses of blood occurring suddenly, or
naturally from external causes ? And finally, who
does not perceive in this an answer to the very just
question of Lister, who, when relating the case of a
lady attacked by dropsy after a severe cough and
haemoptysis, and who had been freely bled five
times — which dropsy he attributed, according to the
received opinion of physicians, to the loss of blood —
wonders much how it happens that dropsy scarcely
ever succeeds to natural loss of blood, however co-
pious, from the uterus, from haemorrhoids, from the
nostrils, or from wounds in any part of the body, but
on the contrary, often follows losses of blood which
occur in the progress of disease ?
But in reference to the abuse of spirituous liquors,
facts obliged all physicians to admit it as a remote
cause of dropsy, although in truth it embarrassed not
a little the theory of Sydenham, and Morton, and
Lister, and Cullen, and also other writers. But
on the appearance of Brown's doctrine, every one
thought they had dispersed all clouds, and with the
game of imaginary, direct asthenia, easily understand
how dropsy might be produced by substances essen-
tially stimulating, and hence become indirectly asthe-
nic, in a disease esteemed on first principles directly
sthenic. And that dropsy is often of this type, even
the celebrated P. Frank does not hesitate to affirm, to
explain how " bibacissimi quique helluones saepius
ex hydrope, quam caeteri mortales conflictantur."
But we, who maintain with the.last and best reformers
of the doctrine of excitability, that stimuli can never
directly induce a weakness of motion, or in their
sense asthenia, at least as long as the part retains its
organization — we really believe that we are not wan-
dering from the truth, in believing that the abuse of
spirits is not the immediate cause of dropsy, even
sthenic, because we have seen that the diatheses of
Brown and others are two abstract conditions, inap-
plicable and contradictory to the facts to explain
which they are applied : but that truly it occasions
the slow abdominal inflammation with which all hard
drinkers are at length attacked, and that these inflam-
mations produce the watery collection which consti-
Finally, no one will oppose the dropsy which suc-
ceeds intermittent fevers as an obstacle to our theory
of its formation ; for in this respect the first practi-
tioners will agree with us in admitting, that most
frequently some slow and occult inflammation is pro-
gressing in one or other viscus, under the appearance
of a rebellious and obstinate intermittent, demon-
strated by the solid swellings which often arise, and
which many have attributed to the bark ; which is
true, but only in this sense that the use of the bark
fostered (as in one way was the opinion of Baglivi)
that inflammatory process which produces the dege-
neration of the organ, erroneously called solid swell-
ing or obstructions. It is not either the ague or
the solid swelling which produces the dropsy, but
only the primitive pathological process, inflammation,
working with the ague in one or other part, and
being increased by the administration of the bark>
which generates both the dropsy and the before-men-
tioned visceral changes. Hence let us conclude with
the celebrated Giannini, " that a physician could
never live free from remorse, whose patients in tertian
ague, treated with bark, die or become dropsical."
Lastly, in reference to hydatids, which are enume-
rated by physicians amid the causes of dropsy, we
must reflect that if these are animals they have no-
thing to do with dropsy, and even when collected
together into a mass, they form a morbid abdominal
swelling, undoubtedly this cannot be considered as
an ascites. If they are not animals, as we believe with
Frank, it may be maintained that these vesicles are so
many dropsical cysts, but not that they can ever be the
cause of true dropsy. And on their production, who
does not see that he is not wandering from the truth,
when he thinks that they also, in the same way as
other cysts, owe to inflammation the process of their
formation ; and that the variety of their structure, and
of the substance contained in them, whether it be
serous, or albuminous, or ichorous, or the consist-
ence of honey, or similar to adipocire, only arises
from the different nature and severity of the inflam-
mation, and its causes, and from the various organi-
zation of the parts in which they are formed ?
Examination of the thirst and toasting which accompany
Two symptoms which the most frequently accompany
dropsy, are thirst and wasting of the body ; hence in
treating of this disease it is impossible to avoid inves-
tigating their causes, the more because the question
concerning the thirst, which is in fact very obscure,
has not been decided either by physiologists or patho-
Commencing always with the method hitherto scru-
pulously observed in our practical and pathological
researches, and which appears to us most conformable
to the dictates of Bacon, we shall first examine all the
facts most important in throwing light on that patho-
logical condition in which living beings are often
found, and which being perceived by the animal, is
called thirst. Now, of these facts, some lead to the
final cause, others to the discovery of the physical
cause, or the organic condition in which it consists.
Among these are the profluvia of the various animal
fluids, during which either a greater or less degree of
thirst occurs. Of these especially, the diabetes, (of
which Frank well said, that it was " vera corporis per
urinam colliquatio)," presents in a terrible manner,
in a greater degree than any other disease, the
symptom of thirst. " Prima (says this great author)
quae in diabeticis quos vidimus occurrebant, et ex
improviso plerumque hominem prehendebant, symp-
tomata, oris scicitas subitanea, ac sitis vix poculo a
labiis remoto recurrens, nec verbis describenda fu-
Diarrhoea, principally of the serous kind, which is
often excessive, is another among the profluvia which
is accompanied by great thirst.
The same may be said of ephidrosis, and more or
less of all copious discharges of the animal humours,
especially the aqueous ones.
Besides the profluvia, other morbid states present
thirst as a symptom to our consideration, and these
are all those in which the animal machine has its or-
ganic movements increased, in consequence of which
some or other of the secretions or excretions are
increased, or increase of heat is developed, which
destroys a proportionate quantity of fluid material.
Now from all these morbid states a fact may be de-
duced, that in these there is produced a want of fluid
or of aqueous matter.
But we have seen before, that in all these conditions
the animal receives the impression, more or less, of
an uncomfortable feeling called thirst, to remove
which it seeks to introduce fluid into the body.
Now as with this it is effectually removed, hence it
follows as a consequence that thirst in animals is a
certain condition of their machine caused in an un-
known manner by want of fluid, and which is per-
ceived by them as painful, and which feeling is in-
tended to warn the individual of the want of fluid;
whence meeting with it, it may restore the health (or
integrity) of the machine. Hitherto, then, we have
spoken of the final cause.
Now if we would approach near to the discovery of
the physical cause, we must shew in what it consists,
from facts, and to what primitive system of organs
that condition, undoubtedly material, appertains,
which, when perceived by the mind, is called thirst.
And to this knowledge it is not improbable we may
arrive, but never can we hope to attain to the know-
ledge of the means through which this condition is
always the consequence of deficiency of fluid. The
facts, moreover, in which it appears to us we may
discover the material cause of thirst, reduce them-
selves to one — the extreme activity of absorption
which the inhalent extremities of vessels of the dif-
ferent surfaces appear to acquire, when animals are in
want of fluid, in consequence of profuse discharges,
or from long abstinence from drink, and which state
is expressed by the word thirst, demonstrated by the
greediness with which fluid is sucked up by the lips
and fauces in these morbid states, and which is also
seen to occur over the whole surface of the body, par-
ticularly in profuse diarrhoeas, or in diabetes, to
such a degree, that this disease was in fact attributed
by some to the extraordinary cutaneous absorption of
humidity from a damp state of the atmosphere. Also
it is well known that in long voyages by sea, in case
of want of water, the sailors try to quench the terrible
sensation of thirst by covering the surface of their
bodies with linen soaked in the sea. After this,
who will say that we wander from the truth, main-
taining that the material condition of thirst exists, in
fact, in this organic and dynamic condition either of a
part or the whole of the absorbent system ; that is, in
increased activity respectively of the action of that
part or whole. But some will argue that if thirst
consists in this vascular condition which is the imme-
diate consequence of want of fluid in the circulating
system, how does it happen that patients are often
manifestly in want of fluid, and yet do not complain
of thirst. " lis," we answer with Hippocrates, " mens
And in fact it is necessary on this point to reflect,
and it may throw no small degree of light on different
facts in the animal economy, both sane and morbid,
that although the material condition of thirst just
mentioned may be present, it is not necessarily a con-
sequence that it should be perceived by the animal.
How often on waking in the morning we feel sud-
denly tormented by great thirst. Who can suppose
that the material condition of this thirst begins imme-
diately and at the very moment of waking ? No one
in his senses. This existed undoubtedly during sleep,
although the individual was not conscious of it. And
in this way there is no obstacle to affirming that thirst
is an organic and dynamic condition, which not only
all animals experience, but also all organized beings ;
since an infinite variety of facts in the vegetable
economy, both healthy and morbid, shews clearly that
the individuals of this class suffer also, in similar
cases, with animals, and most probably there exists
in them a similar condition of a similar system.
But to resume : if in all the above-mentioned morbid
states which thirst accompanies, whether perceived
or not, it is always the consequence of deficiency of
fluid in the circulating system, why must not the
same exist when dropsy accompanies it ? And cer-
tainly, notwithstanding the many wonderful circum-
stances which might induce a contrary opinion, dropsy
is a disease, as the ancients considered, arising from
superabundant " colluvies serosa." For how is it
possible that so extensive a source of secretion and
excretion, into which the immense membranous
surfaces of the abdomen and of the thorax, (when
dropsy arises there), are changed in consequence of
inflammation, should not impoverish the circulating
But how does it happen, here we hear it objected,
that if in dropsy there is thirst, and that the material
condition of thirst is an activity of the lymphatic
system, the disease does not disappear of itself ? And
this happens in fact every time that it is not kept up
by an actual inflammatory state of parts, or accom-
panied by other organic alterations, and the lym-
phatics have not suffered from the compression exer-
cised on them by the long stagnation of the fluid :
and in fact, in practice, cases of dropsy separated from
all these pathological conditions must be rare ; and
also it is very natural to believe, that in dropsies of
some standing, even though the inflammatory state of
the parts in which they arose has disappeared, the
absorbing extremities of the lymphatics of the parts
must have lost their activity : hence the reason for
the necessity, in the cure of dropsy, of bringing the
lymphatic system into this state of thirst ; and if, in-
deed, any of the divisions of that system, not exposed
to one or other of the before-mentioned disabling
causes, have suffered no alteration, in them it must be
increased, in order that by extending it even to those
lymphatics through which the absorption of the fluid
morbidly collected ought to be effected, their inhalent
power may be rendered more active.
Now the primitive organic action of the increase in
the activity of the absorbents, which we have dis-
covered, in every case of want of fluid, to be the ma-
terial condition of thirst, gives us in another manner
the reason of the wasting, whatever may be the form
of the disease which it accompanies, and hence of
that wasting which accompanies dropsy.
For by demonstrating that all the circumstances
appertaining to this wasting (whatever may be the
primary or secondary morbid process which it accom-
panies) prove that its very existence supposes an
impoverished state in the nutritious matter in the
circulating system, and a defect in assimilation, and
the matter itself, which first rendered parts properly
firm and nourished, certainly not vanishing, as we
have proved in another place, except by increased ac-
tivity in absorption, it is a consequence that this con-
dition of this system of vessels exists in all cases of
wasting; and that it is dependent on a hidden rela-
tion between these vessels and the want of nutritious
matter in the circulating system, analogous to what
has been proved to exist between the same vessels and
the want of fluid in the body. Every time, then, that
the general circulating system, to which is owing
the healthy action of organic life, is deficient in fluid
matter, the lymphatics will take on that material con-
dition, thirst, which might be said, in nearly the sense
of Stahl, but really as a property of organized matter,
to be, an appetite for fluid ; and every time that the
same circulating system is in want of that substance
from which it receives stimulus and materials for the
entire preservation of the healthy actions of the animal
machine, one or other of the divisions of the lymphatic
system will take on a state of increased activity, pro-
bably similar to the one already described, and which
may, in a similar manner, be denominated appetite for
And who knows that this condition of the lym-
phatics may not be one of the material conditions of
hunger ? Nor, on the contrary, will it hold good to
observe, that very often, where there is wasting, the
patients do not complain of hunger, and eat little ;
since we have seen that the material condition of
thirst may exist, without the animal being aware of it.
We must here, however, warn our readers, that
we are inclined to believe that there is a difference
between that organic condition of beings, commonly
called hunger, and the state of the lymphatics, which
is the cause of the wasting in all cases in which the
circulating system is in want of nutriment. Perhaps
the greatest number of the causes which give rise to
hunger exist in the stomach ; but we think it not
improbable that one arises from the before-mentioned
state of a part or the whole of the lymphatic system.
But from among the facts which plainly demon-
strate that the appetite, or hunger, of the whole
system of the absorbents, or of some of its divisions,
occasioned by the want in which the animal machine
finds itself of nutriment, is the proximate cause of
wasting, besides those before enumerated, the follow-
ing places it beyond contradiction : — Those who catch
marmots and dormice, assert that these animals are
fat and welt nourished before they retire to their
holes, and very thin and hungry when they wake from
their long lethargy and quit their retreat. Now it is
incontestible that these animals, even during their
long sleep, must be in want of nourishment, because
the organic functions are supported, however weak-
ened they may have become. But they do not take
in any nutriment from without, and must be supplied
by that substance which envelopes parts in a greater
quantity than is essential ; but this cannot be re-
moved and transported into the great circulating
system, except by means of the absorbents ; therefore
an extraordinary activity in these vessels will be the
sole proximate cause of the leanness of parts.
It is, moreover, the extraordinary activity in the
absorbent system, which is the nearest proximate
cause of the defect of either fluid or nutritious matter
in the general circulating system : but there will be,
between one and the other, links of a chain unknown
to us — facts which bind them together more strictly ;
since in truth we cannot yet see, between the one and
the other, that necessary relation which ought to
exist, before it can be maintained that one must be
the effect of the other. Now, every time that, in phy-
siological and pathological researches, we are in a
similar difficulty, no little light is obtained from the
investigation of final causes, very improperly de-
spised and neglected by the modern observers of
It is precisely when we arrive at this point that
we give the name of laws to these ultimate (for us
primitive) facts. Hence, in the present instance, we
consider it to be an established law or property of
the lymphatic vessels in animals, and of those vessels
which supply their place in vegetables, to increase the
activity of their functions every time that the great cir-
culating system, the generator and repairer of organic
matter necessary to the harmonious performance of the
circle of action, which constitutes life, is in want of ma-
terials either aqueous or nutritious.
Hence it is to this same law of the lymphatic
system that is owing (besides the thirst) the wasting
in dropsy, as in other diseases which it accompanies ;
while we have also in the same, the more than suffi-
cient cause of that which we have seen to be most
necessary for the production of the wasting — a defi-
ciency of nourishment in the circulating system.
Who does not see the largest source of the loss of
nutritious matter, and the consequent impoverishment
of the general system, in the profuse secretion and
effusion of the fluid which constitutes dropsy, exuding
from the extensive surface of the inflamed mem-
branes? And in this sense most true is the idea,
which the ancients, especially Aret£eus } distinctly en-
tertained of the analogy between this disease and
diabetes : for in truth there is, no less in dropsy than
in diabetes, a morbid secretion and effusion of nutri-
tious matter, demonstrating at the same time the re-
semblance of some of the characteristic symptoms of
the two diseases ; as the sweet taste, &c. And we have
already shewn, that the excessive secretion called
diabetes, like that of all the other humours, is no other
than one of the symptoms of inflammation of the part
from which it flows, or of another state less acute,
which we have called " Nisus phologisticus."
Explanation of the cure of Dropsy, derived from the
reasoning in the preceding Chapter : reflections on
that proposed by Cidlen, by Milman, by Danvin, by
Rasori : and examination of the "modus operandi"
of remedies to promote it.
It is, above all, the law of the lymphatic system, de-
clared in the preceding Chapter, which relates to its
increased activity during a deficiency of aqueous or
nutritious matter in the circulating system, (whilst at
least its organization is entire), which, whilst it fur-
nishes us with the most plausible explanation of many
obscure points in pathology, regarding certain metas-
tases, affords, above all, a satisfactory one of all the
facts of the cure of dropsy, whether natural, or effected
by medical aid.
For having demonstrated that a dropsical patient
is never cured without the excretion of some of the
animal humours being rendered more active, either
naturally or artificially — and having first demonstrated
so many facts to prove that, under the same circum-
stances, the lymphatic system acquires activity in its
absorbent power, which, in the greatest number of
cases, is perceived by the mind — at the same time
the deduction is not more rigorous than that the dis-
appearance of the aqueous collection constituting
dropsy, not being able to be effected except by means
of the absorbent vessels, is directly owing to the in-
crease of their energy in proportion to the impover-
ished state of the fluid in the circulating system, which
proceeds from the copious secretion and evacuation
of some animal humour, produced either naturally or
artificially by means which increase secretion and
And observe that this theory of the cure of dropsy,
founded on our explanation of thirst, gives also a con-
venient reason for the cure of this disease by the dry
method, although the two would appear to be opposed
to each other. For the greatest cause of the lym-
phatic thirst, ought it not to be abstinence as much as
possible from drink, and the promoting as much as
possible cutaneous exhalation by sweat ? Hence is it
not easy to comprehend the disappearance of the fluid
morbidly collected, in every case in which its origin,
inflammation, has been previously dissipated ?
Hence, therefore, our theory of the cure of dropsy
is not less unshaken and exclusive of all others, than
that already established of its production, since it ex-
plains all the facts which the history of medicine and
daily experience shew to relate to it, while every other
theory is repugnant to one or other series of facts,
the truth of which the authors of such theories seek
to deny. And in reference to those facts first related,
regarding the cure of some dropsies by means of ex-
ercise and abstinence from liquids, being of all others
the most embarrassing to the theories of the causes
and cure of dropsy usually proposed, these authors
refuse flatly to admit them : as, among others, is the
case with Milman and Darwin.
But was it not doubtless from having seen the good
effects, that Hippocrates advised the dropsical patient
" edat sicca et acria, et quam minimum bibat, et quam
plurimum laboret ?" and is it not of still more weight,
since it is not deduced from, or brought forward in
support of, any theory. Celsus says the same, when
he expresses himself thus:— " Potio non ultra danda
est, quam ut vitam sustineat;" to which he adds, that
" multum ambulandum, currendum est," and still
more, " evacuandus est sudor non exercitatione tan-
tummodo sed etiam in arena calida." Galen, more-
over, attests to have seen some dropsical patients
who were cured by abstaining from drink for fifteen
days : and passing over what Pliny writes of a certain
Roman knight, Julius, who abstained through the
decline of his life almost from drinking, and thus
was cured of a dropsy, Bennivenius assures us that a
countryman was cured of a dropsy by abstaining from
drink during an entire year.
But here it is necessary to observe, that we agree with
Milman in discrediting this method of treatment, think-
ing that it rarely can have a favourable result ; and the
reason is this, — that in practice the cases of dropsy are
rare in which the source of the inflammatory process
which produced them does not still exist; in which
case not only is it necessary, as we shall see, to excite
the lymphatic thirst, because it promotes the absorp-
tion of the fluid already collected, but first of all it is
necessary to deprive the dropsy of its source, by over-
coming the inflammation which produces it.
But it will be said, what novelty is there in this
theory of the cure of dropsy, since Cullen has already
stated, that the cure is to be obtained by the evacua-
tion of the accumulated serum, by producing certain
serous excretions, by which means the activity of the
absorbents of the diseased parts may be excited ? But
here we must observe, that though the author has
stated the truth which we have been demonstrating,
yet as it included a fact altogether hypothetical, be-
cause hidden from our senses, it might with equal
reason be denied. Nor, indeed, has Cullen shewn any
more knowledge on the subject than was possessed
by the ancients ; for they also well knew that the
morbid collection of fluid diminished, and even disap-
peared, by reason of abundant serous excretions :
hence, imitating nature, they sought for the proper
means to promote them, and the favourable result
sanctioned, in all times, the powerful effects of eva-
cuants in subduing dropsy. Thus Willis, in explaining
the manner in which purgatives cure this disease,
after having stated that a cathartic " arteriarum os-
cula versus intestinorum cavitates dehiscentia irritat,
ut per haec potius emissaria humor e sanguine re-
jectus exitum inveniat," adds plainly, that " vasa in-
anita aquam mox intercutim resorbent etpartim illico
per sedem, partimque per urinas aut diaphoresi,
foras amandant." But what immediate and strict re-
lation was there ever between the fact of the humoral
evacuation, and the other assumed fact of the in-
creased activity of the lymphatics of the internal ca-
vities, that the last must be the immediate and neces-
sary consequence of the first ? for the very principle
of debility or atony of the general system, and parti-
cularly of the lymphatics, maintained by Cullen as the
principal cause of dropsy, through the defective con-
dition of the absorbents, was incompatible w r ith the
assumed action, since a deficiency in the power of the
absorbents, through weakness or atony, ought to be-
come increased in consequence of a debilitating cause,
such as the evacuation of the animal fluids.
We may repeat the same reflections on the expla-
nation of the cure of dropsy left us by Milman, who
says, <c earn in corpore animali obtinere legem, qua
si medicamentorum ope magna aliqua evacuatio ex
quavis parte provocetur, fit ut fluida quae aliis in par-
tibus latent, resorpta, ad organa remediis sollicitata
deferantur et eliminentur. Hinc humores hydro-
picorum alibi in cavis hserentes ad intestina remediis
purgantibus, vel ad renes diureticis devecti, foras pro-
trudentur." But as these last ideas, in part similar to
those of Willis, with the addition of the hypothesis of
the retrograde motion of the lymphatics, form the
whole of the attractive machinery of the theory of
Darwin on the cure of dropsy, (although both Willis
and Milman and Darwin set off from the erroneous
supposition, that the fluids evacuated by purgative
remedies employed in dropsies are the same as those
morbidly collected in the different cavities constitut-
ing the disease), so the objections which we are about
to bring forward against this last theory will be valid
against the others.
Darwin, after having maintained that the immediate
cause of dropsy exists in the palsy of some of the
branches of the absorbent system, called lymphatics,
and which open upon the surfaces of the larger ca-
vities of the body, and in the cells of the cellular struc-
ture, in which a well-known fluid is secreted for the
purpose of lubricating the surfaces, explains the cure
of it, by means of drastics and purgatives, by sup-
posing that these substances produce, on the internal
surface of the alimentary canal, an inverse motion
propagated to the lacteal and lymphatic vessels, by
means of which, continued even to their open extre-
mities in the different cavities, they promote in these
vessels both a flow of lymph contrary to the natural
direction, and at the same time an increased activity
in the absorbent action of their extremities. Now, in
this theory, the celebrated Darwin has advanced no-
thing new except an hypothesis contrary to the expe-
riments and established observations of anatomists,
which is, that the lymphatics invert their action, in
order to explain the transport of the fluid of dropsy
from the part in which it was collected to the intes •
tines ; a fact already awkwardly assumed by Milman,
and pretty clearly stated by him.
Now, omitting all the valid anatomical and physio-
logical reasons of Professor Jacopi, against this imagi-
nary transport of fluid without its passing through
the circulation, and his own reasons, still more deci-
sive, against the possibility of the lymphatics taking
on the desired inverse action— and omitting no less
our own opinions mentioned in the first part of this
work, in opposition to all the laws of the excitability
of Darwin, and particularly of that torpor, which, in
this place, he makes the principal cause of his imagi-
nary condition of the lacteals and other lymphatics —
we must observe, that in order to maintain that the
fluid evacuated from the intestines, in dropsy, by
means of drastic purgatives, proceeds immediately
from the cavities where it was morbidly collected, it
will be necessary to prove, first, the identity of the
principles composing it ; secondly, to shew that the
same medicines, if administered in a state of health,
or in any case in which a morbid collection of fluid
does not exist, do not produce the same evacuations
from the intestines — which is precisely contrary to the
But in reference to these hypotheses ; first, the
torpor of the extremities of the lymphatics excited by
these remedies : secondly, the retrograde motion in
these vessels, consequent on their application, the most
singular and strange action, and the reality of which
must be most necessary to the theory ; and lastly,
the third, which is put forth as a consequence of the
other two, viz. the increased activity in the mouths of
the absorbents, which open in the different cavities
where the morbid collection of fluid is found.
And in truth, if by laying aside the anatomy of the
structure of the lymphatics, and the experiments re-
lative to it, we could conceive an inverse movement
in them possible, it would be a mutter of indifference
to concede its existence : but it must be impossible
for any one in his senses to believe how such a motion
can increase absorption ; and being changed into an
opposite one, not only is the action not disturbed, but
even rendered more active and increased in force.
Hence something more is wanted than mere dreams,
in order to make us renounce the common opinion,
supported by all the facts relative to the different hu-
moral secretions, rather than the idea that the evacu-
ations from the intestines, under the administration of
drastic purgatives, are merely the effect of activity in
the secreting action of organs produced by these sub-
stances, and precisely similar to the increase of the
saliva or of tears, after the application of acrid sub-
stances to the mouth or the eye.
But coming to the great Italian, the translator of
Darwin, the celebrated Rasori, we must observe, that
in his note to the 200th page of the Zoonomia, having
shewn that he believes with Darwin that the urinary
and intestinal evacuation in dropsies treated with the
digitalis, with drastics and emetics, depend on the re-
trograde action of the lymphatics, in that to the 224th
page of the same volume, he is opposed to this
theory, saying, that drastics and emetics do not cure
the dropsy by producing increased absorbent action
in the lymphatics of one part or another, but by de-
stroying the sthenic diathesis of which the disease is
constituted, the evacuation of the fluid being a second-
Now in these two notes, if it is not wished to blame
the author for a manifest contradiction, it becomes ne-
cessary to infer that he maintained dropsies to be
cured by these remedies by the removal of the sthenic
diathesis ; and besides this, by bringing in the retro-
grade motion of the lymphatics, through which the
evacuation of the water follows, without its passing
through the circulating system. And here we must
remember, that one of Rasori's first disciples, to
whom, as our master, we owe the most distinguished
respect and gratitude, teaching that drastics act by
contra- stimulus, and recommending them in dropsies
termed sthenic, explained the cure not only by an
imaginary primitive vital action, but in addition, he
attributed the evacuations following their administra-
tion to the retrograde action of the lymphatics in-
duced by them. Thus, (returning to Rasori) the
evacuation of the water in dropsy treated by drastic
purgatives, is, in his opinion, a secondary effect ; that
is, to the destruction of the sthenic diathesis which
obstructed absorption, and also to the retrograde
movement induced by them.
Now to say that these remedies destroy the sthenic
diathesis of the lymphatic system, is the same as to
say that they restore it to a natural condition ; hence
this inverse movement will be a natural and healthy
Who among the partizans of the contra-stimulant
doctrine, being convinced by the incontrovertible ar-
guments taken from anatomy, physiology, pathology,
and logic, must have rejected this imaginary condi-
tion of the lymphatics, how can any one of these ex-
plain that, by the simple removal of that sthenic dia-
thesis of the whole body, which we have demonstrated
to be hypothetical, and otherwise repugnant to the
truth, the before-mentioned remedies can bring on
the sudden and often surprising cure of dropsy, which
not unfrequently we have seen to be the effect of their
administration ? In fact, if these substances, by means
of the removal of the sthenic diathesis, restore the ab-
sorbent vessels to their healthy condition, who shall
say that, merely in consequence of this restored na-
tural absorption, the entire subsidence of an ascites,
which is seen to succeed in one night to abundant in-
testinal evacuation, consequent on the administration
of some drastic medicine, takes place ? Besides, if by
the simple removal of the sthenic diathesis of the
body and of the lymphatics, these remedies cure
dropsy, why has no cure ever been obtained, or, as
we maintain, ever will be obtained, with the true
contra-stimulant remedies, such as the lauro-cerasus,
the belladonna, &c. ?
But before terminating this discussion, we cannot
do otherwise than make some observations on the
opinions on which Signor Rasori prides himself, at
page 176 of the third edition of his excellent work on
the Petechial Fever of Genoa. He says, " that his
treatment of sthenic dropsies, (when he was professor
of pathology, and physician to the Hospital of Pavia),
was not conducted with pretended specifics— the lan-
guage of quackery or ignorance, and the cause of
grievous errors in practice — but with those very re-
medies, freely employed, which are adapted to any
other sthenic disease ; purgatives of every kind,
whether mild or drastic, tartar emetic, nitre, abundant
drink, and low diet." Then the cure was not with spe-
cifics, but always withevacuants. Behold the real spe-
cifics for dropsy ! If he wished to prove that, in the
cure of these dropsical patients the only question was to
overcome the sthenic diathesis — by which, according
to him, the disease is kept up, and that the effect of
these evacuants could depend solely on their anti-
sthenic or contra-stimulant action — he ought to be able
to shew cures of dropsical patients with the true con-
tra-stimulants alone, such as the lauro-cerasus, bella-
donna, hyoscyamus, &c : not being able certainly to
assert that they have employed the former remedies
in preference to the latter ; because their contra-sti-
mulant action is directed specially to the lymphatic
system, which would be not only a gratuitous and hy-
pothetical assertion, but contradicted, moreover, by
their effects, always the same, as we have observed in
every state of health and of disease. And here it may
be permitted us to deny absolutely the other merely
systematic proposition, that we sometimes see opiates,
aether, and bark, operate as diuretics ; — a proposition
put forth gratuitously in this place, in order to deny
the diuretic property of those substances which the
observation of all times has sanctioned, and of which
any one may satisfy themselves by taking them in a
state of health.
It is, therefore, for all these reasons, that we main-
tain the humoral evacuation, produced by emetico-
cathartic remedies, to arise from the physical action
exercised by these substances irritating the struc-
tures of the intestine destined for secretion j and that
these, in consequence of the organic laws of irrita-
tion, laid down in the first part of this work, having
their action increased, caused the increased evacu-
ation or secretion to follow.
Nor certainly do the cures of dysentery by Dr.
Pisani, effected by jalap alone, or combined with
neutral salts, or those of his master, Signor Rasori,
by gamboge, present any insuperable difficulty to
this view. In the same proportion that the dejections
were diminished in number, but increased as to
quantity, the malady was cured, for the matter was
thrown out which had occasioned the dysentery in
the interior of the intestines.
Now what we have advanced in reference to
drastics may be extended to diuretic and diaphoretic
medicines, while from these we select the digitalis,
which we are much inclined with Professor Fanzago
to distinguish as possessing two modes of action — one
of irritation, and the other of contra- stimulus ; but in
this sense, that this plant, like all other poisonous
plants, possesses, besides, the principles which exer-
cise an irritating property, producing pain when
in contact with various animal structures ; one
more hostile to life — contra- stimulus. Hence the
first is that which, being unable to be assimilated,
passes with the blood into the organs secreting
the urine, and augments their secreting functions,
from whence arises (in a sense entirely organic)
a painful and irritating effect, whilst the contra-
stimulant principle which it possesses will in-
fluence greatly the cure every time the dropsy shall
have been kept up by a real inflammatory condition ;
but when this shall have entirely vanished, or only
exists with its product, dropsy, an enfeebling of the
whole system of organic actions : even while it pro-
motes humoral evacuations, it will produce a bad, a
most evil effect, with its contra-stimulant property
rendering the vital actions still more weak and lan-
guid. Hence the mixture of spirit with the digitalis,
used by the English, is most reasonable : and, in truth,
the good effect of this mixture in cases of dropsy, as
employed by them, and its diuretic properties con-
tinuing unaltered, ought to be more than sufficient
to prove that the power of digitalis in promoting the
evacuation of urine arises from a very different cause
than its contra-stimulant action.
And in reference to these principles, which cannot
be assimilated by the circulating system, we do not,
in truth, see sufficient reason to marvel so greatly as
Dr. Morechini does, in order to determine us to be-
lieve that every kind of urine is not always separated
from the blood, but that it may succeed to a direct
transference of different substances from the chylo-
poietic to the uripoietic viscera, independent of the
sanguiferous system. Nor can the results of the ex-
periments of Darwin or Rasori move us, which would
appear to demonstrate, that no traces were found in
the blood of some substances introduced into the
stomach, while they were manifested in the urine.
Might not these elements be separated in the blood,
and recombined with others which no longer present to
our senses the usual signs of their presence, and even
elude chemical reactives, but become recomposed
in the secreting apparatus of the different animal
fluids. It may be added also, that we are inclined to
believe with MM. Henry and Pearson, that if these
substances are really discoverable in the blood, they
should be sought for in the arteries, and not in the
But if in these substances with which dropsy is
cured we must not maintain any virtue to exist ex-
cept the sensible quality of promoting this or that
humoral secretion or evacuation, how will the pa-
thologists explain, under their employment, the dis-
appearance of the fluid morbidly collected in the dif-
ferent cavities which constitutes dropsy ? and, in truth,
for any one, not so foolishly ready to attribute hypo-
thetical properties to these or those substances, nor to
describe certain conditions of organs never demon-
strated to exist by physiological or pathological ana-
tomy, the cure of dropsy, by the use of remedies
which the observation of all time has proved to be
most efficacious, was certainly still problematical.
Thus no one hitherto has answered the difficulties
proposed by Rasori, against the cure of dropsy by
substances possessing the power of increasing the
secretion of urine. He thus expresses himself: —
" Whatever may be the kind of dropsy, the fluid
which constitutes it is extravasated in a cavity, that
is to say, out of the circulation, while, on the con-
trary, the supposed diuretic action is exercised on
the kidneys, which is to say, within the course of the
circulation. This being the case, the diuretic might
produce a diabetes, by the increased quantity of
urine which the kidneys might separate from the
blood in less time than ordinarily ; but this action has
nothing ro do with the extravasated lymph, which is
beyond the action of the kidneys, and removed from
the mass of the blood." Which first reflection might
be understood as being just when extended to the
action of em eto- cathartic remedies.
But the cure of dropsy is still a secret to the most
moderate and reasonable among the contra-stimu -
lists, who maintain that these substances are indirect
contra-stimulants, while, besides it not being easy,
as we have already seen, to comprehend how with
the single removal by their action (which is a debi-
litating one), of the imaginary sthenic state of the ab-
sorbents, certain sudden cures of dropsy ensue. It is,
moreover, absolutely impossible to explain how the
same substances are necessary to the cure even of
those dropsies in which the general circle of action is
decidedly enfeebled and languid, and which they call
asthenic, and in which it becomes necessary to ad-
minister them at the same time with stimulant re-
And from this fact it would have been equally im-
possible for us to understand the cure of dropsy, if
we had not proved that organic law of the lymphatic
system which respects increased activity of the ab-
sorbent system, when there is a deficiency of fluid
occasioned by the great loss of the animal humours.
In the meantime, having demonstrated by facts that
dropsy is merely a product of inflammation, we may
well comprehend how it could be overcome, and its
source removed, by these evacuating, and hence de-
bilitating, substances, but never how the disappear-
ance of the fluid would succeed, and still less how
they must be necessary for the cure of dropsy, not
only when inflammation no longer exists, but there
is a decided enfeeblement of vital action, and in
which the practice of all physicians has shewn it to
be necessary to administer stimulants. But it was by
the proposed law of organic life, that through the
humoral discharges, promoted by these evacuating
substances, inducing necessarily in the circulating
system a relative defect of fluid, the lymphatics must
take on a state of thirst, or an increased activity in their
absorbing power, that we have understood easily
all the facts relating to the cure of dropsy, and have
been able to establish, on this important pathological
question, a theory which partakes in no way of the
nature of an hypothesis.
The indications of the cure of Dropsij, derived from
the opinions lately explained.
The curative indications of dropsy cannot be reduced
to fewer than these two general ones : —
1. To destroy the source of the morbid collection
2. To evacuate the existing collection of fluid.
And these, in truth, were always reputed as indica-
tions, by all physicians ; but inasmuch as no one, up
to this time, has displayed or established irrefragably
the true source of dropsy, through all the facts ap-
pertaining to the disease, hence in the discrepancy
which existed in the theories invented in reference to
it, in the different schools, the curative method an-
swering to this first indication must necessarily have
been erroneous and uncertain. And even in refer-
ence to that method of the physicians, most attached
to, and most uniform in following their preconceived
ideas, a method which appeared to the greater num-
ber, supported by facts, viz. the stimulating one — that
is, precisely the one opposed to what is called for to
subdue the pathological process which constitutes
the source of dropsy — it is not to be wondered at that,
in following such a course, they should have been
little fortunate in the cure of the disease; more espe-
cially the physicians at the conclusion of the eighteenth
century, who were not permitted by the laws of ex-
citability to adopt at the same time evacuants, except
when, by good fortune for their patients, they de-
ceived themselves in their judgment of the vital action
of the latter medicines.
But we have with sufficient reason established — be-
sides having demonstrated that dropsy is a morbid
collection of fluid of new formation, or consisting of
a morbid secretion formed by the surfaces of the parts
where it is found — that the pathological condition
taken on by these surfaces, which enables them to
produce the disease, is no other than inflammation.
This, we say, we have proved from the four following
facts : —
1 . That the dropsical fluid differs from that which
naturally exhales from the cavities of the body.
2. That it is exactly similar to what is visibly pro-
duced by inflammation.
3. That it is found only with organic alterations,
undoubtedly the product of inflammation.
4, That all physicians have seen dropsy succeed
to diseases maintained by them to be decidedly inflam-
Now, investigating the facts contained in the works
of the greatest observers, taken from the daily prac-
tice of ail physicians, relative to the method of cure
in dropsies — in the examination of which we have
seen that every cure of this disease has always been
obtained by one or other of these two methods, viz.
either by the employment of substances capable of in-
creasing one or other of the humoral discharges,
either alone or in combination with others which en-
feeble organic movements ; or by administering with
these evacuants substances capable of exciting actions
and functions which maintain the necessary nutrition
of parts, (with which facts we have demonstrated the
theory of diathesis, in the production, and the cura-
tive induction drawn from it, to be inconsistent) —
we may plainly maintain that every case of dropsy
which presents itself in practice will certainly be one
of the following three: —
1. Either the dropsy accompanies, and hence is
kept up by inflammation of the parts in which it is
found ; —
2. Or the inflammatory process may have already
disappeared, either naturally or by the use of medi-
cine, and the general circle of vital actions may be in
a state nearly natural; but because the absorbing
power of the lymphatics may have suffered by the
long compression made by the fluid, and because the
natural action of the absorbents is not sufficient for its
removal, it is necessary to increase and render more
active this absorbing power ; —
3. Or not only may the inflammatory state have
ceased, but, besides, the organic actions of the animal
machine may have become enfeebled and languid,
either because the presence of the fluid morbidly col-
lected may disturb the proper performance of chyli-
fication, sanguification, and consequent nutrition, or
perhaps, unhappily, organic alterations exist in one
or other of the viscera, from the preceding inflam-
mation, which prevent the regular exercise of their
functions, on which the well-being of the animal
Every one will see, that in all cases of dropsy the
original cause of the morbid collection is not always
subsisting, but cases may be seen in which it is al-
ready overcome. It will be, therefore, of the first
importance to the happy conclusion of the treatment,
to discover first, in every case of dropsy which pre-
sents itself, whether the cause which we have marked
out exists or not ; and in case it does not, if the ge-
neral system be in a tolerably healthy state, or lan-
guid and enfeebled : hence one of the curative indica-
tions, that of getting rid of the morbid collection of
fluid, is, as we have seen, common to all cases of
Considering, then, the first indication, we may fear-
lessly maintain, that it can alone occupy us in the cases
in which the inflammation still exists, which keeps
up and increases the morbid collection of fluid : but
besides attending to the first, it is also necessary at
the same time to fulfil the second indication. Now
the means which carry this into effect, are, as all
know, the evacuation of blood, and the administration
of those substances which enfeeble directly the im-
pulses of organic action, and inflammation, which is
the increase of these, contra-stimulants, properly so
called, and also of other medicines which produce the
same effect, by promoting the evacuation of the animal
In reference to these last substances it will be well
to remember also, that whilst they appeal' to be the
most proper to subdue dropsy, and hence were always
most commonly used, inasmuch as they fulfilled both
indications, viz. the destruction of the source of the
morbid collection of fluid, and also the expulsion of it,
through the medium of the evacuation caused by their
action, and the consequent increase in the activity of
the absorbents, in consequence of the impoverished
condition of the fluid in the circulating system.
And on this subject it will be necessary to observe,
that these substances are of themselves sufficient to
effect alone the cure of dropsy, not only in the cases in
which the inflammatory process actually existing,
and which keeps up the complaint, is very slight, but
also to destroy or remove the feebleness of organic
action consequent on the evacuation of fluid.
Every time, on the contrary, that the inflammation
no longer exists, the necessity for using the means ne-
cessary to overcome it must cease, and we must avoid
both bleedings and contra-stimulant remedies ; but the
indication being the same, to disperse the fluid already
collected, we must look to those remedies which ex-
perience has demonstrated to be the most powerful for
Now these we shall see to be all those substances
which promote the evacuation of the serous fluid :
but the evacuation of these animal fluids is shewn by
experience (we beg pardon of those who consider
them to be contra-stimulants) to induce an enfeebled
state of the organic functions. Being obliged ne-
cessarily to run the risk, by removing, even with
these remedies, the morbid collection of fluid, of
suffering the patient to perish through inanition
or real weakness, it will be our aim to administer
also substances demonstrated by experience to be
capable of increasing vital power, and of maintaining
the necessary nutrition of parts.
It being conceded that the inflammation no longer
exists which produced the dropsy, but there is really
only present the languid condition of the vital forces,
any one may see, in this case, how much the necessity
is increased of administering the substances before
mentioned, at the same time with those which sti-
mulate the absorbents, that is, evacuants — which, as
we have seen, are always necessary to the cure of
And here it may be observed, that with our doctrine
we may finally cut the knot of the controversy among
physicians, as to the advantage or non-advantage of
the paracentesis in ascites.
For if the morbid collection of fluid be enormous
and of long standing, will it not be obvious to
think that the absorbents would suffer, as has
already been mentioned, by the pressure of fluid
against membranous surfaces ? and hence will it not
be a good practice, taking away the pressure by the
immediate evacuation of the water, to induce the de-
sired active state of the lymphatics by remedies ? But
that which on this subject it will be equally impor-
tant to determine in practice, is, whether an inflam-
matory condition of the membranous surfaces be ac-
tually existing or not.
Now the presence of this condition, even in ascites
of long standing, is in truth much more frequent than
has been commonly believed by physicians ; and we
incline to attribute principally to this state the rare
occurrence of the radical cure of ascites by paracen-
tesis, (to a degree, that some even reject its employ-
ment as useless), because after the operation blood-
letting is ' no longer thought of. We shall not,
however, be far from the truth, if we lay it down as a
rule that tapping is not, in general, desirable in an
actually inflamed condition of the membranous sur-
faces ; and if it is wished to adopt it, we ought not af-
terwards to desist from blood-letting, (in proportion
to the severity of the inflammation which continues),
at the same time using evacuating remedies and real
contra-stimulant medicines. When, however, we dis-
cover, that without doubt the inflammatory process
which produced the ascites is overcome, then the ope-
ration of tapping will be more than desirable, and
still more so in the case in which the general system
is in a sensible state of feebleness.
But to our theory of the cure of dropsy, not less
than to its cause, which appears to us to embrace all
sorts of cases appertaining to this disease, we are
persuaded that some one will think it right to oppose
a grave objection in the radical cure of hydrocele
obtained by incision, and the injection of some
stimulant fluid. How, in fact, will he say, can we
recognize the origin of the fluid of a hydrocele from
an inflammatory state, if the means employed, with
the happiest success, are, in fact, to produce an in-
flammation in the same structure ? In fact, every
one has, in the opinions already delivered, sufficient
materials to overcome such imposing difficulties with
In Chapters II., III., and IV. 3 we have shewn that
it is a given degree of inflammation, and no other,
which generates the fluid in which dropsy exists.
Hence, where is the wonder, that by changing by art
the inflammatory condition of the tunica vaginalis,
which produces dropsy, into that which pours out
coagulable lymph, the means are taken away from
the membrane of pouring out water, and even the
cavity obliterated which contained the fluid ?
2 1 8
Hence, therefore, all other dropsies, whatever be
the part in which they are found, must recognize
the universal cause (inflammation), hitherto irre-
fragably demonstrated as their origin.
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